Nomenclature of Diseases: Its Reception

J. Roy. Coll. Phycns Lond.

A History of the College's Nomenclature of Diseases: its reception

A. H. T. ROBB-SMITH, MD, FRCP

The first part of this history gave an account of the Nomenclature itself and the now to K steps that led up to its publication in February 1869; it is necessary consider how it was received by the medical profession and the changes that took place during its subsequent revisions. v The British Medical Journal and Lancet had given detailed and favourable accounts of the Nomenclature in 1868 on the basis of the proof copies, describ- ing it as a work of almost national importance, so that when it was distributed - to the professions the notices were laudatory but comparatively brief, a few errors and omissions were pointed out and regrets that there were not more definitions. The reception in Scotland was very different. A special meeting of the Council of the Royal College of Physicians of Edinburgh was held on ? 15 March 1869, when Dr Duncan suggested that as the Treasury's decision to distribute copies of the Nomenclature rendered it official, he considered that the London College should from courtesy have communicated with the other -1 Colleges of Physicians, and he was far from satisfied that the Nomenclature was acceptable. A committee was appointed to examine the book and report to the Council, while the President undertook to write to the Member of Parliament requesting him to ask a question in the House of Commons. The answer by the Chancellor explained the importance of a uniform nomenclature and continued: 'The Government do not adopt or recognise this work the sense of making themselves responsible for the correctness of its >? contents, but they do so far adopt and recognise it, in that it is their wish . . . that it should be employed generally in order that the terminology used by

medical men should not be such as to mislead. . . . We have had no communication with the medical bodies of Scotland and Ireland on this subject v and I am not aware whether they concur with the London College of Physicians upon it.' The April number of the Edinburgh Medical Journal contained a note about * the distribution of the Nomenclature to the profession which ended, 'without offering any further comment for the present, we must express our surprise and regret that this step was taken without even the courtesy of a formal rv Vol. 4 No. 1 October 1969 5 J. Roy. Coll. Phycns Lond. communication with the Royal Colleges of Scotland and Ireland'. Two " months later there appeared in the Journal a report on the Nomenclature published at the request of the Council of the Edinburgh Royal College. It was a lengthy and somewhat verbose document in which the Council stated that they had attempted to examine this important work without prejudice, in spite of the fact that they were never consulted about it, that they did not propose to draw attention to its merits, but as it contained many errors and omissions, they could not give it their unqualified support. - Then followed a most detailed and meticulous critique in which every possible defect was displayed. The arrangement was too anatomical and it would have been desirable to distinguish between diseases with and without postmortem examination. The Latin translations were unduly pedantic and although the provision of definitions was most important, many were poor and insufficient. Examples of errors were the inclusion of diseases of the spleen in the digestive system instead of with the ductless glands, and fatty kidney being wrongly included under Bright's Disease. Rodent ulcer should have been classed as a non-malignant condition, while capillary bronchitis and second- ary haemorrhage following childbirth had been omitted. The report ends: 'The Council are deeply sensible of the many difficulties attending the preparation of a work like the Nomenclature of Disease, especially difficulties of classification and those which arise from imperfect knowledge and varieties of opinion but they think they have given sufficient evidence to show that if the Government intends to make any particular use of this work, it should be previously subjected to careful and enlightened criticism from various quarters.' Dr Stark, the superintendent of statistics at the Scottish General Register Office, who had been a member of the Nomenclature committee, naturally ignored the work and continued to publish his mortality returns arranged according to the curious classification which he had devised in 1864. A more objective criticism was offered by Walter Moxon (1870). His basic objection was that the College Nomenclature was based on morbid anatomy rather than the clinical manifestations of disease and often the doctor had no idea of the underlying pathology, particularly when the patient recovered. 'We want to have the names of diseases to refer primarily and chiefly to their clinical nature, and secondly to have an arrangement introduced such that the nature of disease may be accurately defined apart from its anatomical results; and thirdly, and chiefly that the nomenclature shall correspond to the actual grouping of the symptoms of disease rather than to the anatomical or physiological divisions of the body and its functions . . . We require good

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names for the clinical groups of symptoms.' Having put forward the problem, Moxon could offer no real solution, merely giving as examples of the sort of r thing he was seeking Duchenne's approach to nervous diseases with his recognition of clinical syndromes rather than pathological lesions. The?creation of a diagnostic nosology, or perignosis as Moxon called it, is r at the present time exercising the minds of those who hope to achieve clinical a from technical and , diagnosis with the aid of computer. Apart conceptual Problems, such experiments can be successful only if they incorporate a uniform nomenclature for the disease states that are to be identified, and it was this which the College had endeavoured to provide. The fears of Major Graham, the Registrar-General, that the College Nomenclature might be used to strengthen the hands of the advocates of national registration of disease, were fully justified. This idea, initiated by Dr and Sir Ward i v Henry W. Rumsey strongly supported by Benjamin Richardson and the British Medical Association, which had set up a Com- mittee on the Observation and Registration of Disease in 1865, was steadily * even Charles Dickens was enlisted in the for in I gaining adherents; cause, All the Tear Round he wrote, 'It concerns a man more to know the risk of the fifty illnesses that may throw him on his back than the possible date of the ?ne death that must come. We must have a list of the killed and the

, wounded too.' Witness after witness before the Royal Sanitary Commission of 1869 stressed its importance and the British Medical Association requested Dr Sibson to represent their official views to the Commissioners, but this he - never did. However, in October 1870, Dr Sibson was the spokesman for the BMA when a deputation waited on the the President of the Board of Trade to explain the importance of general registration of disease; during the course of his speech, Sibson pointed out the necessity of employing a uniform nomenclature of disease in the preparation of the returns 'and thanks to the labour of the Royal College of Physicians that nomenclature is secured'. The President of the Board of Trade, though apparently sympathetic, > evaded any responsibility for such a scheme and suggested that it would be undesirable to go into the matter until the Report of the Royal Commission had been considered by the Government. One of the Commission's resolutions was, 'That in addition to the duties Prescribed by the existing Registration Acts, it should be made the duty of the Registrar General and of the District Registrars to register disease and sickness or specified cases of disease and sickness'. Dr Farr had supported this v Jdea and one of Major Graham's assistants, Mr John Lewis, gained considerable notoriety by a lecture which he gave to the Social Science Associ- ation on 'Suggestions for National Returns of Sickness', which was J. Roy. Coll. Phycns Lond.

subsequently reprinted as a pamphlet. In fact, it had never been suggested that there should be returns of all cases of sickness but only of those treated at ? public institutions. In spite of continuous pressure, official inertia succeeded in preventing any practical steps being taken, but it would seem that the medical profession had not fully appreciated the implications of their advocacy of national registration of sickness. In about 1876 certain towns began to insist on compulsory notification of infectious diseases, with the threat of lines for practitioners who failed to conform, and there was an immediate outcry. Medical men in private practice maintained that compulsory notification would violate the professional confidence between patient and doctor, turning him into a spy or common informer, forced to betray his patient; it was suggested instead that the practitioner might complete a notification form which he would hand to the head of the house- hold who would be responsible for informing the health authority. In spite of vociferous opposition, compulsory notification of infectious disease gradually gained ground, but it was not until 1889 that the Local Govern- ment Board summoned up courage to sponsor the Infectious Disease Notification Act. Naturally, it was the College Nomenclature that was used in the returns the Board published. The College Nomenclature Committee hoped that its work might initiate an international nomenclature of disease; that was the reason for giving disease names in several languages and for distributing the Nomenclature to all the governments, universities and medical societies of the civilised world. This endeavour had little impact on European countries, but it had an important influence on the United States of America. At the International Statistical Congress held in London in 1860 it had been reported that the American Medical Association had recommended the adoption of Farr's 1845 Statistical Nosology in the USA, and that it had been in use in the states of Massachusetts, Rhode Island, South Carolina, and Kentucky since 1850; Massachusetts and Rhode Island had also tried the classification which Farr had presented to the 1853 Congress, but had not found it as satisfactory as the old one. The Surgeon General's office at Washington received the copy of the College Nomenclature sent to the United States Government and on 21 April 1869, Surgeon J. K. Barnes, in a letter of thanks to the President, wrote, 'Should the proposed nomenclature be adopted by the Registrar General of England, it would appear desirable that it should be known in all countries where the English language is in common use and with the view of laying it ? before the profession in the United States the attention of the American Medical Association will be called to the compendium at their approaching

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annual meeting'. The AMA set up a committee on nomenclature of diseases under the chairmanship of Professor Francis G. Smith and printed 1,000 r copies of the English and Latin portions of the College Nomenclature with a Prefatory note inviting criticisms and suggestions. Five hundred copies were distributed but only three comments were received, all unfavourable. The * committee met in Philadelphia in 1870 and the majority decided that the was to meet , College Nomenclature inadequate the needs of the American profession, as it was unsatisfactory and incomplete in its details, and that the AMA should appoint a committee to prepare an American nomenclature for adoption and observance in the United States. However, there were two dissentients. Dr Austin Flint felt that if a different nomenclature were adopted, the advantages of uniformity of nomenclature in the two countries would be lost and that uniformity outweighed any present defects which * could ^ be remedied in the future; furthermore, knowing the difficulties in preparing such a work, he doubted if it would ever be completed. He believed that the College classification was excellent and much to be pre- ? ferred to Farr's nosology. Dr Stanford Chaille went even further. He recognised that with some members of the committee national and anti-British feeling constituted serious obstacles to the College Nomenclature, but he was anxious to see the adoption of ? one simple nomenclature for the medical profession throughout the civilised world. By adopting the English nomenclature they would best aid this great end. The majority report was accepted and a committee was set up to prepare an American nomenclature, but in the meanwhile, the newly established Bureau of Census adopted the College classification for the mortality statistics of the ninth census of the United States. After two years' work and fifty meetings, the AMA committee presented their nomenclature at the annual conference at Philadelphia and it was published as an appendix to their transactions. It was proposed for adoption, but a minority consisting of ^rs J- J- Woodward, A. B. Palmer, G. A. Otis, and Austin Flint said that there had been inadequate time for studying the new nomenclature and Proposed that 1,000 copies should be printed for distribution to the medical Journals and profession and the matter considered again at the next confer- , ence. This was agreed and when the AMA met in St Louis in May 1873, the committee reported that the distribution of the American nomenclature had taken place, but they had not received a single comment from a journal and only two from practitioners, so they presumed that it was satisfactory, as your committee are not willing to entertain the only other conclusion that men of culture and practical men are indifferent upon a subject of such

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r" importance', and so they recommended that the American nomenclature should be adopted. However, Dr J. J. Woodward pointed out in considerable detail the inferiority of the American nomenclature to that of the Royal College of Physicians, and proposed that the American nomenclature should not be adopted, but that a committee of three should be appointed to com- municate with the Royal College of Physicians and negotiate for represent- ation of the AMA at the decennial revision of the Nomenclature. This amendment was adopted and Drs Woodward, Jarvis, and Alfred Stille were appointed as the negotiating committee. In the same year the American Public Health Association recommended the provisional adoption of the College Nomenclature in the US. It was being used in the American army, and in 1874 the US Marine Hospital Bureau (the forerunner of the United States Public Health Service) adopted it for use by their medical officers, while the Government printing office published an edition of the Nomenclature, omitting the French, German and Italian terminology and correcting a few errors. Furthermore, when Billings produced the Index Medicus in 1879, he pointed out that the nomenclature and classification he would use for analysing the world medical literature was that propounded by the College. So far as is known, the decisions of the American medical organisations were not reported in the English medical journals and so the College may have been unaware of the large measure of success they had achieved in their endeavour to introduce an international nomenclature of disease. However, they would have been aware that the Registrar-General was prepared to recognise their Nomenclature. Until 1874, the issuing of a death certificate was a voluntary act on the part of the practitioner, but after the passing of the Registration Amendment Act, it became a statutory duty. In connection with this change, Major Graham wrote to the General Medical Council: 'A few years ago the College of Physicians appointed a Committee which published a Nomenclature of Disease, which work, by direction of Her Majesty's Government, I distributed to every authorised practitioner in England and Wales. I will avail myself of this opportunity of printing in the new book of forms of (death) certificates, a list of names of fatal diseases sanctional by the Committee of the Royal College of Physicians.' The College did not take any steps to revise the Nomenclature until 10 January 1877, when a new edition committee was set up, and it may be that the sudden death of Francis Sibson in Geneva in September 1876 was a reminder of their resolution to undertake a decennial revision. The committee reported in a fortnight, with a statement that the first edition had taken twelve years to complete, that the cost of a reprint would be exorbitant and so it would be better to prepare a new and revised edition. However,

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nothing happened until 15 October 1879, when it was decided to instruct " Messrs Harrison to print 500 copies of the 1869 edition, which should suffice for two or three 100 were sold each would T years?about copies year?and provide a copy for each member of the revision committee. In the same year the Registrar-General, Major Graham, retired at the age of > Seventy-six. Dr Farr, although in poor health, hoped to succeed him, but, as usual, political nepotism prevailed, and the appointment went to Sir Brydges Heniker, a former secretary to the President of the Local Government Board and, perhaps more important, brother-in-law of Lord John Manners. Dr Farr, hurt and disappointed, resigned; his successor as Superintendent of Statistics was Dr William Ogle, an equally remarkable man. Son of the Regius Professor of Medicine at Oxford and one of Arnold's last pupils at Rugby, he took Holy Orders and a first in natural science at Oxford and then decided to read medicine. He graduated in 1858, was on the staff of St George's Hospital and became a Fellow of the Royal College of Physicians in 1866. In 1872 he gave up his hospital appointment on account of ill health and , became medical officer of health for East Hertfordshire, where he soon attracted the attention of Sir George Buchanan, who recommended him for the Somerset House post. A learned statistician without Farr's humanity, Ogle brought the Registrar-General's department up to date and took part *n the meetings of the International Statistical Institute, which introduced the International List of Causes of Death, the ideal for which Farr had struggled and which the College had hoped would be facilitated by its Nomenclature. ? However, Aristotle was Ogle's real enthusiasm; a few years after he joined Sir Brydges, he published the authoritative translation of De partibus animalium, and at intervals until his death in 1912 further translations of the * Aristotelian Corpus appeared. Ogle decided that the classification that Farr had been using for the Registrar-General's annual reports must be changed. Until 1880 all the main tables were classified according to the 1853 list with slight modifications, and .ln addition there was a single table of total deaths, using the classification of the College Nomenclature. Ogle wished to use a single classification and that which had the sanction and authority of the Royal College of Physicians was of course the one which naturally recommended itself for selection'. But there were difficulties; it was essential for administrative purposes to make the change in the first year of a decade, and the College Nomenclature had yet to be revised. More important, the College list was a nomenclature of all diseases, arranged in a logical manner, whereas the Registrar-General needed a statistical classification for practitioners' death certificates, and the mam purpose of his publication was the prevention of disease. It did not

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matter that the College list contained the names of many diseases that were seldom, if ever, fatal, but it did matter that many deaths were ascribed to ~ vague indeterminate conditions, equally applicable to several distinct diseases. As Ogle wrote, 'If the Royal College of Physicians, besides providing an authoritative nomenclature of diseases, could also prevail on medical men to use no other terms in certifying as to causes of death than those thus sanctioned, the tabulation of deaths would be carried out with much greater precision and in a much more satisfactory manner than is possible with the present lax use of medical terms'. The arrangement of the College list was in the main pathological, whereas from a preventative point of view aetiology was more significant, and this 11 applied in particular to injuries, where it was more important to know how the accident occurred than the lesion which resulted from it. In July 1880 Dr Ogle wrote to the College setting out his problem and suggesting that from his point of view it would be an advantage if the Latin nomenclature were omitted, as many of his registrars were unfamiliar with the classics and misread practitioners' diagnoses; he also gave a list of items that had appeared on death certificates but that were not in the Nomenclature. The President of the Royal College of Physicians had also received a letter from Dr Billings, writing as Vice-President of the National Board of Health in Washington, enclosing a copy of resolutions passed at a meeting of State and Municipal Registrars of Vital Statistics held in Washington in May, 1880. This proposed that the College Nomenclature should be used for registration purposes and that a committee should indicate the most urgently needed additions to the College committee on the revision of the Nomen- ~ clature, with a view to obtaining a uniform system in Great Britain, her colonies, and the United States. This was reported to the College on 29 July 1880, and the President, Sir Risdon Bennett, said that he had sent some copies of the Nomenclature to Washington, indicating that he would be glad to receive suggestions for the revision. It was now apparent that the College must take serious steps to revise the Nomenclature, and in October the President formally appointed a nomenclature committee. The main committee consisted of the President, College officers and twenty Fellows, together with the President of the College of Surgeons and eight other surgeons, and included Jonathan Hutchinson, Dr Ogle for the Registrar-General, John Simon and Dr Buchanan for the Local Government Board, and representatives from the Army and Navy. There were no representatives from Scotland, but the College received assistance from the Registrar-General of Ireland. Dr Ord was appointed

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secretary and received a honorarium of 100 guineas. There was a classification subcommittee and the revision of the various sections was handled by Pairs of specialists who reported their recommendations to the main committee. There is a manuscript list of the sections with the names of those who would examine them, and against Jonathan Hutchinson is written omniscience'. The committee first considered whether the College Nomenclature could be combined with the type of classification of causes of death that Dr Ogle wished to introduce in the General Register office, and decided against this. However, Ogle, as a member of the Committee, was able to modify the arrangement to meet his needs and from 1881 (the volume was not published until 1883) the Registrar-General's Reports introduced a classification which m essentials was the one adopted in the first revision of the College Nomen- clature. It was certainly a great improvement on Farr's classification. The Registrar-General for Ireland agreed to use Ogle's classification, but Scotland stood aloof. In Edinburgh, Dr Robertson, who had succeeded Dr Stark as superintendent of statistics, continued to use Stark's classification until 1876, when he adopted Farr's list, but he finally accepted the 1883 volume, published in 1886, of Ogle's classification, and so far as is known there were no repercussions from the Edinburgh Royal College. Dr Billings's committee had also been hard at work in Washington, and at the end of October 1880 sent a list of suggestions to Dr Pitman, the Registrar, for the consideration of the College committee. Billings also mentioned that a member of his committee, Dr Charles Folson, the secretary of the Board of Health of Massachusetts, would be visiting London in November and would hope to confer with the College committee. The American proposals dealt both with the nomenclature of certain sections?emphasising the importance to them of a clear nomenclature of malaria?and with the classification of the general sections. They also raised the point that Moxon had discussed ten years before: whether it would be possible to make a distinction between a clinical and pathologico-anatomical nomenclature, the first being names of symptoms or groups of symptoms, the second the results of disease. This might be achieved if it was directed that certain terms should be used to express the result of a postmortem examination only, while other terms were to be used in the absence of such an examination. Later, Dr Folson reported the result of his meeting with the College committee and Dr Buchanan, who was dealing with the section on com- municable diseases. He said that the committee and Dr Buchanan had too little practical knowledge of malaria to enable them to deal fully with that

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matter, but they had considered very favourably the other four recommendations of the American committee. The sub-committee submitted its final revision to the main nomenclature committee on 3 May 1882, when it was accepted, but there were considerable delays before the Nomenclature was published. There was again some trouble with the Treasury, who pointed out that if , they had been informed that the Nomenclature was to be revised they could have obtained a cheaper contract price from the Government printers. They requested the College to advise them in advance before undertaking the next ?? revision. Consequently, there were two issues of the revision, one sponsored by the College, which appeared in August 1884, and an edition on smaller paper issued by the Stationery Office and distributed to practitioners in the summer of 1885. n Sir Risdon Bennett's preface described the main changes since the first edition, and the purpose of a nomenclature, emphasising that the classification of disease names was not a simple catalogue of diseases but had a of disease was not specific function. A perfect statistical registration yet ( available but statistical registration had different functions in different departments; the Registrar-General was concerned with deaths and applied the principle of one death, one cause, the Local Government Board was interested in the prevalence of disease, while registrars in hospitals wished to study the nature of disease and its complications, as well as causes of death. The changes in this first revision were considerable. Unhappily, all were which was a that to a extent definitions omitted, retrograde step large r nullified the purpose of the Nomenclature. It is true that in the original edition these were far from complete, yet they provided clear guidance as to what a disease term meant and offered a basis for a more accurate classification of ? disease both nationally and internationally. The committee did not attempt to justify this omission. " The classification had been altered to conform with the American suggestions, supported by Dr Ogle. General diseases were now divided into four ,| categories: y 1. dependent on morbid poisons (specific febrile diseases) 2. due to external agents other than morbid poisons (parasites, poisons, diet, injuries due to climate) i 3. developmental disorders 4. other general diseases (benign and malignant neoplasms, rheumatism, gout, tubercle etc.).

There had also been considerable rearrangement of the local disease sections,

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but the only major change was that diseases of the lymphatic system had been gathered together and placed near diseases of the spleen and glands of internal secretion. Certain terms had been omitted, the most important being puerperal fever which in future was to be characterised as puerperal pyaemia, septi- > caemia, or erysipelas in pregnancy; simple cholera, which had confused the was to and would be known as v Spanish quarantine authorities, disappear epidemic diarrhoea. There were a few new terms indicative of clinical advances?epidemic rose fever or Rotheln, which had recently been separ- ated from measles, myxoedema (the term devised by Ord for Gull's cretinoid condition in women), idiopathic pernicious anaemia, haemophilia, lympha- denoma, arteriocapillary fibrosis, and a more detailed characterisation of the various forms of malaria. The medical journals noted the new edition with reviews which were favourable, but lacking the revivalist enthusiasm of fifteen years before, for vital statistics had lost their glamour, and there were a few critical letters > from psychiatrists and neurologists who were not satisfied with the way their specialities had been handled. In the preface to his forty-sixth report the Registrar-General mentioned that the Government had sent a copy of the revised edition of the College to medical in the 'Under ^ Nomenclature every registered practitioner country: these circumstances it is surely not unreasonable to ask that medical men shall in stating causes of death conform to the terms adopted and recom- ? mended by the College. Were they to do so the process of classification of deaths in the General Office would be much and j Register simplified facilitated.' The Nomenclature had now achieved its place as the official guide for medical terminology. Sir Andrew Clark was President when the third edition (second revision) ?f the Nome?iclature was prepared and all went very smoothly, as a definite Pattern had been evolved. The main committee, with representatives from * the College of Surgeons and the Services, was appointed in January 1892, with Dr Bristowe as chairman and Dr Payne as secretary; as before, sub- committees dealt with the individual sections, reporting their recommendations to the main committee which approved the final version in March over some of terms , !895. The minor difficulties with the psychiatrists the they wished to introduce were soon resolved, and the Treasury was warned well in advance. This was the first occasion in which there was a single issue ? ?f the Nomenclature, published by the Stationery Office and printed by Eyre and Spottiswoode, which was distributed to all practitioners in October 1896 and attracted little attention in the medical journals.

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The most important change was the addition of a new section relating to bacteria and recognising that certain diseases could be caused by pathogenic organisms. The College was cautious, distinguishing between diseases in which organisms were present in the lesions, and those in which the organism was believed to be the cause. A few new names were added, such as Malta fever, actinomycosis, foot and mouth disease, Hodgkin's Disease, pellagra, | and diabetes insipidus, while Rotheln became rubella, much to the annoy- ance of the Lancet. The list of operations was rearranged and the Italian 1 nomenclature, which had always given trouble, was omitted. While the College was preparing the third edition of the Nomenclature, \ important events were taking place in the field of international mortality ' statistics. The International Statistical Congresses had been replaced by the and met International Statistical Institute when this in Chicago in 1893, Dr , Jacques Bertillon, as rapporteur of a committee appointed for the purpose in Vienna in 1891, presented a classified nomenclature of causes of death which was recommended for international use. He explained that it was derived from that used in Paris, but he had taken cognisance of various classifications used in other countries, and it is easy to trace its descent from Farr's Statistical " j Nosology of 1842 through the more advanced arrangement introduced by the College in 1869 to Bertillon's Nomenclature des causes de deces of 1886. General diseases were subdivided into epidemic and other general diseases, followed by diseases affecting the individual systems, and ended with malformations, injuries, and ill-defined conditions. The classification was favourably received, and in 1898 the American Public Health Association recommended that it be adopted for the registration of vital statistics in the United States, Canada, and Mexico, and that it should undergo decennial revision under inter- ~ national auspices. When the International Statistical Institute met in , Christiania in 1899, Dr Bertillon was able to report that the majority of the countries (Great Britain being an exception) had accepted the classification,

- and in the following year the first of the decennial revision conferences was held in Paris, with twenty-six nations taking part. Thus it was that the International List of Causes of Death came into being. The revision conferences met in Paris until 1948, when the World Health Organisation became " I responsible for the revisions. The United States abandoned the College Nomenclature for the International List in 1900, reiterating the ideas that had led the College to draw up its Nomenclature in 1869: 'It is much more important that deaths reported in the same terms shall everywhere be ?'] compiled under the same titles than that the assignment (classification) be absolutely correct'. The College had hoped that their efforts might lead the way to an

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international language of disease, but the vital statisticians were ill equipped to prepare this and the practising physicians did not participate in its deliberations; nevertheless, it was the classification which the College had evolved that formed the basis of the International List, and it was its realistic idea of a decennial revision that made the acceptance of an international classification > a practical proposition. The College had taken no part in these international deliberations, and it may well be that the purpose of the Nomenclature was becoming uncertain and its revision a ritual task, but the College was still turned to when particular matters of nomenclature were in doubt. The Infectious Diseases (Notification) Act required that cases of puerperal fever should be notified to the local authorities, but there was considerable doubt as to what conditions should be included under this term. In 1898, the Vestry of Bethnal Green instituted proceedings against a doctor who had failed to notify a case of puerperal peritonitis, but the magistrate took the view that as puerperal peritonitis was not mentioned in the Act, the doctor was not guilty. The Public Health Committee of the London County Council, on v behalf of the Vestry, appealed to the President of the College, Sir Samuel Wilks, for a ruling on the matter and a committee was set up which gave as Jts opinion that puerperal pyrexia should include pyaemia, septicaemia, peritonitis, and acute inflammation of the pelvis directly resulting from childbirth. Public Health authorities throughout the country issued direc- tives in accordance with the College's advice, but the drafters of the various Public health acts ignored it, and the matter remained in some confusion until the Puerperal Pyrexia Regulation of 1951 provided a precise definition ?f the conditions to be notified. In 1900 a College committee, set up following a request from the Society ?f Medical Officers of Health, reported on the nomenclature to be used in certifying deaths from diarrhoea. The authorised term for dysentery, which had formerly been called simple cholera, was epidemic diarrhoea which was classified under the infectious diseases, but practitioners were unwilling to use this term for fatal cases, as the public regarded diarrhoea as a mild disease insufficient to cause death. Such cases were, therefore, certified as gastroenteritis, mucoenteritis, or gastric catarrh, which were classified under diseases of the digestive tract, with the result that the incidence of dysentery could not be ascertained. The College recognised the difficulties and after five years of careful- enquiries authorised the term 'epidemic enteritis' or zymotic enteritis' as a synonym for epidemic diarrhoea, and urged upon practitioners the entire disuse in medical certification of such terms as gastroenteritis, mucoenteritis, or gastric catarrh as synonyms for epidemic diarrhoea; it was not a very successful solution to a problem which still

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troubles epidemiologists and vital statisticians, and in the next revision of the Nomenclature epidemic enteritis disappeared and was replaced by infective < enteritis which continued to be the preferred term. The fourth edition of the Nomenclature was prepared during Sir William Church's presidency and for the first time the Royal Colleges of Physicians of Edinburgh and Ireland were represented on the committee appointed in > 1902. In addition, Sir Clifford Allbutt, Regius Professor of Physic at Cam- bridge, together with his professor of pathology, Dr Sims Woodhead, were nominated to the committee, but there was no representative from Oxford, as Sir William Osier did not take up office until 1905. The sub-committee which was responsible for the detailed work had Dr Pye Smith as chairman . and Dr T. A. Ormerod as secretary and all went smoothly, save that Henry Butlin and Watson Cheyne took umbrage and resigned when the main committee amended certain of their recommendations for the section dealing with diseases of the breast. The revision was completed and submitted to the general committee on 31 July 1905, and the Stationery Office published the Nomenclature at the end of 1906, distributing 40,000 copies to registered practitioners and providing the College with 500 copies free of charge. The British Medical Journal described it as being above criticism, but the Lancet did not give it a notice. There had been changes in arrangement and in detail. The general sections were arranged alphabetically rather than by groups and there were no translations of the list of operations. Simple continued fever had been replaced by 'pyrexia of uncertain origin' and rubella was now called German measles, but the number of new terms added was small. Shortly before the College began its revision, Dr Tatham, successor to Dr Ogle as Medical Statistician to the Registrar-General, had been anxious to revise his classification and had had to adopt a similar procedure to that used in 1881. By 1902 there was a uniformity of classification in England, Scotland, and Ireland and, as Tatham wrote, 'a consideration that may account in > some degree for the readiness with which the new departure has been accepted by the medical profession generally is probably this, that the list of diseases has been arranged in substantial conformity with the Nomenclature of the Royal College of Physicians'. The International List of Causes of Death was gaining adherents among the nations for the registration of deaths, and in 1909 Dr Stevenson, Tatham's successor, advised the Registrar-General that it would be advantageous if * Great Britain adopted this classification from the year 1911. Accordingly, on 20 October 1910, Bernard Mallet, the Registrar-General, informed the President of the College of his intentions, explaining that the change would ?

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greatly facilitate international mortality comparisons, but that it meant the t abandonment of the classification devised by the College, although the Nomenclature itself remained a standard of reference. In the United States Dr Cressy Wilbur, chief of the division of vital ^'Statistics of the Bureau of Census, who had been the driving force for the List in that the AMA in 1907 > adoption of the International country, persuaded to set up a committee on nomenclature and classification of disease and in 1908 the committee recommended that at the 1910 Revision Conference the

. International List should be recast into three distinct but interrelated sections:

\1. a list of causes of death 2. a classification of sickness and disability 3. an international nomenclature of diseases and injuries with precise agreement on the meaning of terms.

Sir Thomas Barlow was President in July 1912 when Comitia appointed >ihe nomenclature committee for the fifth edition. The committee was now as representative as possible of the interests of medicine and vital statistics in the country. Dr Frederick Taylor was the chairman of the working com- * mittee, with Dr Guthrie as the secretary, and it was hoped that the revision would be completed by 1916, which it was. Soon after the committee began its meetings, a letter was received from Dr Cressy Wilbur, as chairman of the AMA nomenclature and classification committee, enquiring whether the ?College would be willing to cooperate with his committee on the proposals that they had made in 1908. The College committee considered the matter and decided that as the College Nomenclature of Disease and the Manual of the " International List of Causes of Death issued by the General Register Office were to serve no should be made to amal- t designed different purposes, attempt gamate or incorporate them. There was further correspondence with Dr Wilbur in which he explained 1 i that his committee hoped that the college would be willing to collaborate in -he third of their proposals?'An international nomenclature of disease and injuries with precise agreement on the meaning of terms', but the College A was only prepared to supply his committee with proofs of the College Nomenclature when it was ready. Dr Wilbur informed the AMA in July 1914 that there would be delays before he could report any progress with the College of Physicians and a year later he had to report that, owing to the war there was little prospect of collaboration with the College, that there were great difficulties in the preparation of a good nomenclature, and that the wisest course was to 'discharge his committee and wait until the College nomenclature was

19 J. Roy. Coll. Pliycns Lond.

completed. Despite the war, four or five members of the College committee had over ninety meetings and the revision was completed by March 1916. H It was decided to omit the French, German, and Latin translations; it was also suggested that in future the list of operations should be omitted. In January 1917, the committee received a request from the War Office and the Medical Research Council for guidance on the most suitable names for trench fever, epidemic or infective jaundice, and Weil's disease. The general nomenclature committee met on 23 July 1917, when Dr Taylor presented the revision and explained that the delays had been due to difficulties with printers, but the work was approved with a few amendments, and was published by the Stationery Office later in the year. ? In the preface the committee justified the omission of the foreign names by explaining that the original intention of the compilers of the first edition to found an international nomenclature of disease had not been realised, and that it was impossible to guarantee the correctness of the French and German equivalents except by international agreement. The Latin names were often translations of English phrases, and created hybrid terms which it did not seem necessary to maintain; furthermore, the numbering of terms and cross references was omitted, which further reduced the usefulness of the ? Nomenclature. The British Medical Journal observed that the revised Nomenclature was not likely to be used as a work of reference; this displays all too clearly the change in attitude to the College Nomenclature from the days when it was heralded as a work of almost national importance. In 1920 the United States Bureau of Census published a Standard Nomen- clature of Diseases, Pathological Conditions, Injuries and Poisonings, which had * been prepared by a committee under the chairmanship of Dr W. H. Davis, the chief statistician, and was based on several nomenclatures in use in the United States, as well as on the College Nomenclature; the initiative had come from a committee of the armed and public health services which had been ? set up two years before, but as the Nomenclature was only an alphabetical list of disease names with code numbers, it received little support. However, in 1928, at the suggestion of Dr George Baehr, the New York Academy of Medicine held a conference on nomenclature to which representatives from the principal medical societies, the armed services, and public health bodies were invited; it was decided to prepare a 'Standard Classified Nomenclature of Disease', and Dr H. B. Logie was appointed as executive secretary to < coordinate the undertaking, which was given financial support by the Commonwealth Foundation. In the following year a conference of expert statisticians, held in Berlin under the auspices of the League of Nations,

* J. Roy. Coll. Phycns Lond.

promulgated a resolution calling upon the member nations to undertake work of this nature. This was the situation in July 1929 when Comitia approved the committee nominated by the President, Sir John Rose Bradford, to prepare the S1xth edition of the Nomenclature. Sir Robert Hutchison was the chairman of , the small executive sub-committee on classification and Dr Bosanquet was secretary and editor. The work was soon completed, and was published in 1931. The committee had received from Dr Logie the draft of the American Standard Classified Nomenclature but did not consider collaboration with the to , United States, nor take cognisance of the international attempts achieve a uniform nomenclature of disease. The College Nomenclature followed the restricted approach which had been adopted for the fifth edition. It was a s list of names of diseases, symptoms and pathological conditions arranged anatomically without any indication of their significance, together with an appendix containing lists of tumours, malformations, parasites, and vectors ?f diseases and poisons. A new feature was a list of the terms added since the last revision. The largest number occurred in the section on nervous and mental diseases, but looking at the list as a whole, it is interesting to note how some terms omitted after the first edition of the Nomenclature came back Jnto usage, and the delay in adopting familiar terms; for example, common c?ld, anorexia nervosa, hypertension, subacute bacterial endocarditis, Addisonian anaemia, and cardiac asthma first appear in this revision. Two years later the American Standard Classified Nomenclature of Disease appeared and was hailed with great enthusiasm. It was not strictly a nomenclature, but a disease classification, arranged both anatomically and aetiologically, with code numbers for each term, and its prime purpose was to facilitate the filing and retrieval of clinical records in hospital. It was widely adopted in this country as well as in America. However, a need was growing for a morbidity classification for statistical purposes, in which similar diseases were grouped together, as was the practice in the International List of Causes of Death; classifications of this type had been propounded at the revision conferences since 1900, but had failed to gain general acceptance. This need became urgent during the war, for the armed services and also for was the emergency medical services of the Ministry of Health, and so it that in 1944, the Medical Research Council published A Provisional Classifi- cation of Diseases and Injuries for use in compiling Morbidity Statistics, and the ' United States Public Health Service A Manual for Coding Causes of Illness According to a Diagnosis Code for Tabulating Morbidity Statistics. In spite of the difficulties of war conditions, there had been close collaboration between the English and American committees preparing these two classifications, but it

21 J. Roy. Coll. Phycns Lond.

was recognised that both were provisional, and experience in their use might provide a basis for an international classification. r This was the climate of thought when the College, under Lord Moran's presidency, resolved to undertake the seventh edition of its Nomenclature. The main committee included for the first time representatives from the various specialist groups such as the British Association for Dermatology, the British Orthopaedic Association, etc., and also the President of the newly established Royal College of Obstetricians and Gynaecologists; the Regius Professors of Oxford and Cambridge were omitted. The classification sub- committee had Professor Sir Henry Cohen as chairman, with Professor Barnard as secretary, and specialists were responsible for the preliminary revision of the different sections. The revision was completed in January 1946, but publication was delayed until 1948 owing to printing difficulties. The arrangement of this revision was a considerable departure from the previous edition and the reasons for this were explained by Professor Cohen in the preface. The sub-committee at first considered recommending the adoption of the American Standard Nomenclature for use in this country, as this would encourage international comparability and the Standard had been carefully prepared and was proving useful. However, it was felt that the aetiological classification adopted was too rigid and that as it had been designed primarily for statistical purposes it departed too widely from their aims; so it was decided to provide a new version of the College Nomenclature, but following very closely the classification of the Standard. Accordingly, the first part was a general aetiological classification, incorporating the sections on parasitic and infective agents, and tumours, that had previously been in appendices. This was followed by an anatomical arrangement of systems to which the aetiological classification was applied. It was stated that the Nomenclature had been designed to serve as a basis for a statistical code, though it is difficult to see how this could be achieved, as it was essentially a dual axis classification with numerous repetitions, and the only groupings possible were either aetiological or anatomical, which inevitably bring together diseases very different in character. A novel and valuable addition to the Nomenclature was a list of eponyms which was compiled by Professor Cohen and was a forerunner of the more extensive dictionaries of eponyms of Aimes (1959) and Leiber-Olbrich (1966). Reviews of this new edition of the College Nomenclature were not very enthusiastic and it was unfortunate that it appeared only a few months before the International Statistical Classification of Diseases, Injuries and Causes of Death which was to revolutionise international vital statistics. This classification, which was issued under the aegis of the World Health Organisation

22 J. Roy. Coll. Phycns Lond

as the sixth revision of the International List of Causes of Death, had developed " from a collaborative enterprise initiated by the United States with representatives from the British and Canadian governments and the Health Section of the League of Nations; it was to prove an effective and practical instrument for both morbidity and mortality analysis and, with slight modifications r introduced during the seventh and eighth revisions, it has been found to be more useful for records than the more Standard r classifying hospital complex Nomenclature of the AMA. The Army Medical Services, whose needs had stimulated the College to prepare a nomenclature nearly a century before, / m 1952 abandoned the use of the College Nomenclature returns and adopted *he List indeed that time no was A International instead; by recognised body following the arrangement of the College Nomenclature for its reports. The latest revision of the Nomenclature took place in 1959 during Sir Robert Piatt's Presidency. Lord Cohen was again chairman of the committee, with Dr J. F. Stokes as secretary, and although additional terms were introduced in many of the sections, the general scheme remained unaltered; o this eighth revision was published in 1960, but received as cool a reception fr?ni the medical as its r press predecessor. On 17 February 1969, the President, Sir Max Rosenheim, gave a dinner at the College to commemorate the centenary of the Nomenclature and an- nounced that the College, after consultation with the Ministry of Health and the General Register Office, had decided not to prepare any further revision the Nomenclature. In conversation the President subsequently said he felt sure that the College would be ready to collaborate in the preparation an , international nomenclature of disease. It must be confessed that the Nomenclature in its present form would not appear to serve a very useful purpose. It consists of a list of disease terms, the majority of which are descriptions of pathological lesions or symptoms rather than as nor diseases, without any indication to their meaning, does their mode of arrangement, which is according to aetiology, reveal this; un-

- doubtedly it is convenient to have in a readily accessible form lists of the approved botanical and zoological names for fungi, bacteria, parasites and disease vectors, but this is not strictly an essential part of a nomenclature of disease, and their continued inclusion was questioned during the fifth revision of ? the Nomenclature. On the other hand, the International Classification of Diseases provides a convenient and workable method of classing, indexing and retrieval of the - names of disease conditions, whether these appear on death certificates, morbidity reports, certificates of incapacity or clinical records; it is certain that computer techniques of the types introduced by Howell and Loy (1968)

3 23 J. Roy. Coll. Phycns Lond.

and Smith and Melton (1965) can greatly facilitate the process and perhaps point the way to better methods of classing this information. However, there is no means of knowing whether these disease names are always used in the same sense, nor is there any canon of reference, other than a medical text- book or dictionary, as to how they should be used, for there is no official source book of disease definitions. The problem is not one of clinical diagnosis but of terminological usage, and there are innumerable instances of mis- understandings and false assumptions consequent on such confusion; a recent example was the apparent disparity between the types of chronic respiratory disease occurring in this country and the United States, which was shown, when identical diagnostic criteria were used, to be due to differences in nomenclature rather than pathology. Accordingly, there is a need both nationally and internationally for a nomenclature of diseases of the type envisaged by the College over a century ago, as authoritative medical terminology which could ensure that 'medical observation is occupying itself everywhere with the selfsame diseases'. The original version of the Nomenclature was a notable attempt to provide this and, as far as the English speaking world was concerned, was to a considerable extent successful. Subsequent revisions receded further and further from this objective in spite of recurring international pleas for such a work. The Council for International Organisations of Medical Sciences, with the support of the World Health Organisation, is now considering the preparation of an International Nomenclature of Disease to: 'provide a method by which physicians and medical research workers throughout the world when using a term to describe a disease, would use it in the same sense. This would simplify communication and would also facilitate the storage and retrieval of information, statistical analysis and computer operation. These objectives can best be attained by providing approved names and synonyms of diseases in one language together with a definition where this is necessary for compre- hension. From these definitions, approved names and synonyms in other languages would be established.' In essence, this recapitulates the preface which Sir Thomas Watson wrote for the first edition of the College Nomen- clature and it seems a happy coincidence that this new project should be initiated in the centennial year of its publication. It is to be hoped that the College, drawing on a wealth of knowledge and experience, may be willing to take part in what will be a difficult but worthwhile task, and so fulfil the high ideals that inspired its President and Fellows a hundred years ago.

Acknowledgements It would not have been possible to write this account but for the help and

24 J. Roy. Coll. Phycns Lond.

collaboration of many people; in particular I am indebted to the Registrar, " the Harveian Librarian, Mr Payne, Mr Michael Reed, the Registrar- General, Lieutenant-General Sir Robert Drew, Dr W. Macleod, the Registrar of the Royal College of Physicians of Edinburgh, and Dr Martin Gummings, Director of the National Library of Medicine. >- This article is abridged from the complete manuscript 'A History of the College's Nomenclature of Disease'' which is available in the Library of the Royal College of Physicians.

SOURCES K Manuscript British Museum 1863 f * t> ^SS 43399 111/113. ' 1 Nightingale Papers ublic Records Office Treasury Papers T1/688B/12992/1869; T27/161; T1/6888B folder 4041. *?yal College of Physicians Annals Box File Publication of the Nomenclature of Disease 1869 and its subsequent Revision Committee Minute Book of 5th Edition (4th Revision) 1912-17. 2 volumes. "minted f. Papers imes, A. (1959) Maladies et Syndromes Rares ou Peu Connus. Paris. American Medical Association Transactions (1870) 21,121: (1872) 23,42: (1873) 24,45. Journal (1907) 48,2055: (1908) 50, 1731: (1909) 52,2005, 2058: (1910) 54,2078: (1911) 57, 133: .(1912) 58, 1134, 1897: (1914) 63, 90: (1915) 65, 114. 'itish Association for the Advancement of Science Report of fourth meeting held at Edinburgh in 1834. London (1835) p. xxxix. Report of the fifth meeting held at Dublin in 1835. London (1836), p. 251. British Medical Journal (1868) ii, 110, 316, 396: (1869) i, 29, 55, 130, 194, 219, 250, 498: (1870) i, 586: (1871) i, 367: (1872) i, 242: (1877) ii, 244: (1884) ii, 418: (1885) ii, 30, 234, 248, 317: 221: 292: 892: 320. . (1896) ii, 469: (1898) ii, 1703: (1907) i, (1918) ii, (1932) i, (1949) ii, on Standardized Nomenclature in News- , O.M.S. (August 1968). Working Group Medicine,

t letter, 36. * ^?ugres internationale de Statistique Compte rendu des travaux. Bruxelles 1853 (1854): Paris 1855 (1856): Vienna 1857 (1858): , London 1860 (1861). avis, W. H. (Editor) (1920) Standard Nomenclature of Diseases, Pathological Conditions, Injuries and "oisonings for the United States. Washington Government Printing Office. Sickens, C. (I860) All the Tear Round, 86, 227, 228. Edinburgh Medical Journal (1868/69) 14, 959, 1115. a|r, W. (1856) Report on the Nomenclature and Statistical Classification of Diseases for Statistical Returns. London. reenhill, W. A. (1854) Report on the Mortality and Public Health of Oxford during the years 1849, 1850. Appendix C. Oxford: Ashmolean Society. rlovvell, R. W. and Loy, R. M. (1968) Brit. J. prev. soc. med., 22, 178. nstitut internationale de Statistique Bulletin (1889) 4 ii, 252, 264: (1892) 6 i, 260, 263: (1893) 8 i, CII.CV, 304: (1896) 9 i, 85, 91: , (1900) 12 i, 68, 270. L"ncet (1855) ii, 36: (1867) i, 636: (1867) ii, 141, 230, 686: (1868) ii, 152, 285, 704: (1869) i, 20, j44, 306, 324, 343, 375, 410, 690, 824: (1885) i, 638, 852: (1896) i, 1803: (1896) ii, 411, 493: (1?32) i, 948, 1013: (1949) i, 656: (1961) ii, 584. Returns Sickness. London. | W J' (1870) Suggestions for National of .'u ber, B. and Olbrich, G. (1966) Die Klinischen Syndrome. Berlin. ??le> H. B. (Editor) (1933) A Standard Classified Nomenclature of Disease, New York: The Common- wealth Funds. 1 edical Research Council (1944) A Provisional Classification of Diseases and Injuries for use in compiling statutes. Series No. London: HMSO. , Jn^bidity Special Report 248, Medical Times and Gazette (1865) ii, 120. J. Roy. Coll. Phycns Lond.

Moxon, W. (1870) Guy's Hosp. Rep., 3rd ser. 15, 499. National Board of Health (1882) Annual Report for 1880. Washington, pp. 7, 537, 595. Newsholme, A. (1896) Statist. Soc. Jourti., 59, 1. '? Nightingale, F. (1859, 1863) Notes on Hospitals. London. Ord, W. M. (1881) Biography of Francis Sibson in Collected Works 4 vols. London. J Registrar General of England and Wales. Annual Reports: First (London 1839); Second (London 1840); Fourth (London 1842) [Statistical Nosology p. 147. Comment on Report of Royal College of Physicians of Edinburgh, p. 206]; Sixteenth on Nomenclature and the statistical classification of disease (London 1856) [Report * p. 71]; Thirtieth (London 1869); Thirty-first (London 1870) [Appendix C p. 258 'Remarks submitted to the consideration of the Royal Sanitary Commission by the Registrar General of England and Wales']; Forty-fourth (London 1883) [New Classification p. xvii]; Forty-sixth ? (London 1885); Sixty-fourth (London 1903) [Classification p. xxx]. Rolleston, H. D. (1909) Lancet, i, 1437. J Royal Sanitary Commission (1871) 2nd Report, vol. I. Smith, J. C. and Melton, J. (1965) Data Control for Anatomic Pathology, Cleveland. Stark, J. (1859/60) Edinb. Med. J., 5, 1069. Times (1868) Sept. 12; Dec. 30 (1869) March 20. Trans. Epid. Soc. (1858) [in Sanitary Review (1858) 4, 47]. (1862/66) 2, Appendix. United States Public Health Service (1944) A Manual for Coding Causes of Illness According to a Diagnosis Code for Tabulating Morbidity Statistics. Miscellaneous Publications No. 32. Washington. ?*? Wilder, R. M., Allan, F. N., Power, M. H. and Robertson, H. G. (1927) J.A.M.A., 89, 348. World Health Organisation (1948) Manual of the International Statistical Classification of Diseases, * Injuries and Causes of Death. Sixth Revision of the International Lists of Diseases and Causes of Death. Geneva.

Doctor and Patient It is sometimes considered that the modern physician differs from his forbears in that he takes care to explain to his patient the nature and outcome of disease. A modern obituary might well read: 'His manner of explaining the disease and the remedies recommended, was peculiar to himself and singularly 1 happy. It was a short compressed lecture, in which the objects in view and the means by which they were to be obtained were developed with great clearness i of conception and in such simple unadorned language as was intelligible to his patient and satisfactory to his colleague. Before his time it was not usual ' for the physician to do much more than prescribe remedies for the malady and encourage the patient by such arguments of consolation as might present themselves to humane and cultivated minds. But as the assumed gravity and outward signs of the profession were now considered obsolete customs and were by general consent laid aside by the physicians; and as a more curious anxiety began to be observed on the part of the patient to learn everything connected with his complaint, arising naturally from the improved state of general knowledge, a different conduct became necessary in the sick room.' The phrasing of this quotation gives away its date. These were remarks made by Sir Henry Halford about Dr Matthew Baillie who died in 1823 leaving most generous benefactions to the College.