The Kindness of Strangers: Kinds and Politics in Classification Systems - administrative history of large-scale classification systems

Library Trends, Fall, 1998 by Geoffrey C. Bowker

   In considering the international form of medical certificate of cause of
   death, the Expert Committee had recognized that the situation of an aging
   population with a greater proportion of deaths involving multiple disease
   processes, and the effects of associated therapeutic interventions, tended
   to increase the number of possible statements between the underlying cause
   and the direct cause of death: this meant that an increasing number of
   conditions were being entered on death certificates in many countries. This
   led the committee to recommend the inclusion of an additional line (d) in
   Part 1 of the certificate. (ICD-10, 1996, vol. 1, p. 18)

Thus there is now one more blank line on the form to indicate multiple causation (see Figure 2).

Figure 2. The Internationally Recommended Death Certificate Form.

Cause of Death                                      Approximate
                                                    interval
                                                    between onset
                                                    and death

         I
Disease or condition directly     (a) ...           ...
leading to death(*)
                                  due to (or as a
                                  consequence of)

Antecedent causes                 (b) ...           ...

Morbid conditions, if any,
giving rise to the above cause,   due to (or as a
stating the underlying            consequence of)
condition last                    (c) ...           ...

                                  (d) ...           ...

         II
Other significant conditions      ...               ...
Contributing to the death, but
not related to the disease or
condition causing it              ...               ...

(*) This does not mean the mode of dying--e.g., heart failure, respiratory failure. It means the disease, injury, or complication that caused death.

A major change incorporated in the classification scheme in the last two revisions has been the so-called "dagger and asterisk" system. This is a means of cross-referencing manifestations and underlying causes for a particular disease. The ICD and its instruments have thus, through a pair of small-scale formal changes (a line here and an asterisk there), loosened up their implicit causality and thence their picture of the past. Histories now can be more fluid than they once were.

The classification scheme is, of course, responsive to changes in medicine and medical technology in many ways--there are constant changes in the allopathic understanding and description of diseases reflected in the classification scheme itself. The development of new diagnostic technology in the 1940s led to the reclassification of tuberculosis, for example (otherwise there would have been too many cases). The National Tuberculosis Association's (1955) edition of Diagnostic Standards and Classification of Tuberculosis notes that new laboratory tests had made it more difficult to decide whether a particular case of TB was active or inactive-activity could now be seen at sites previously considered inactive, and yet one would not necessarily want to call the "new" active sites cases of TB since they very well may not progress to the point of needing treatment. The committee cites the 1955 version of the book: