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 nomen- clature 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 com- munication 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 knowl- edge 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 A J. Roy. Coll. Phycns Lond. 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 con- siderable 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 com- pulsory 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.