NATIONAL CENTER Series 4 

For HEALTH STATISTICS INumber 5 

VITAL and HEALTH STATISTICS 

DOCUMENTS AND COMMITTEE REPORTS PROPERTYOF THE 

PUBLICATIONS BRANC~ 

EDITORIAL LIBRARY 

History of the United States


National Committee on


Vital and Health Statistics


1949-1964


A summary of the Committee’s history and working arrangements prepared for its 15th anniversary meeting. 

Washington, D. C. 

U.S. DEPARTMENT 

HEALTH, EDUCATION, AND 

John W. “Gardner 

Secretary 

June 1966 

OF 

WELFARE Public Health Service 

Wil Iiam H. Stewart 

Surgeon General 
Public Health Service Publication No. lCIOO-Series 4-No. L 
NATIONAL CENTER FOR HEALTH STATISTICS 

FORREST E. LINDER, PH. D., Director 

THEODORE D.WOOLSEY,Deputy DhCCtOT 

OSWALD K.SAGEN,PH.D.,~JJiJtant Director 

WALT R.SIMMONS,M.A.,Stati-rtical Advi.ror 

ALICEM.WATERHOUSE, M.D.,~g&az ~hi$or 

JAMES E.KELLY,D.D.S.,Dental ~dvi~or 

LOUISR.STOLCIS, M.A.,
~xecutive Oj?cer 

OFFICE OF HEALTH STATISTICS ANALYSIS 

IWAOM. MORIYAMA,PH. D., Chief 

DIVISIONOF VITAL STATISTICS 

ROBERTD. GROVE,Pa D., Ch’c-f 

DIVISIONOF HEALTH INTERVIEW STATISTICS 

PHILIPS. LAWRENCE,Sc. D,, C%tif 

DIVISIONOF HEALTH RECORDS STATISTICS 

MONROEG. SIRKEN,PH. D., Chief 

DIVISIONOF HEALTH EXAMINATIONSTATISTICS 

ARTEURJ. MCDOWELL,Chief 

DIVISIONOF DATA PROCESSING 

SIDNEYBINDER,Chief 

PubIic Heolth Service Publication No. 1000-Series 4-No. 5 

Library o{ Congress Catalog Card Number 66-60075 
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CONTENTS


Page 

L	 In&oduction


The Committee


Basic Committee Structure and Functions


Membership


Strucmre andOperatingAutiori~


Statement of Committee Functions


11. Review ofComineeAchievements


Vital Statistics


Definitions of Live Birth and Fetal Death --------------------------


Tabulation of Fetal Deaths


Improving Fetal DeathStatistics


Occupation Item on Census Schedules and Vital Records


National VitalStatisticsNeeds


Need for National Marriage Statistics


Improving National Divorce Statistics


Morbidity Statistics


Case Registers


Glossary of Terms Used in Morbidity Statistics


Desi~of NationalHealthSurvey


Hospital Statistics


Community’s Need for HospitalStatistics


Adaptation ofICD for DiagnosticUses


Hospital Statistics and the National HealthSurvey---


Militay HealthStatistics


Classification Drafts forICD Revision


Mental Disorders


Cardiovascular Diseases


Congenital Defects


Causes Peculiar to Perinatal Period


Accidents, Poisonings, and Violence (E Code)----------------------


Accidents, Poisonings ,and Violence(N Code)----------------------


Physical Impatiments


Operations and Treatments


Fertili~andPopulationStatistics----------------------


NeededFertility Statistics


Later Review ofNeededStatistics


Recommended Census-Period Studies


Fertility Measurements


Two BrieferSmdies


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25 
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CONTENTS—Con. 

II. 

111. 

Review of Committee Achievements—Con. Page 

Medicolegal Death Statistics 

Improving Me&colegal Certification 

Improving Medicolegal Death Statistics 

Quantification of Wellness 

Health Economics 

Structure and Basic WorkingArrangements 

Structure of the National Committee 

Membershipof theCommittee 

Oficers oftieCo~iuee 

Structure and Activities ofSubcommittees 

Membership and Officers 

Types of Sukomminees 

Working Procedures andRecords 

Relations Between the Committee and Its Subcommittees 

26 

26 

28 

29 

31 

32 

32 

32 

32 

33 

33 

33 

35 

35 

36 

38 

Appendix. Origins of tie National Comti~eeSystem 

References 
IN THIS REPORT aye backgyownd mateyials foy the 15th annivenayy 

meeting of the United States National Committee on Vital and Health 

Statistics, which was held on December 14 and 15, 1964, in Washington, 

D. C. The puvpose of the anniversary, in the wo~ds of the Committee’s 

ChaiYman, hr. RobeYt Dyav, was “to view the Past and help plan fov the 

futuye. It Neayly all pYe5ent ad foymey membevs of the Committee 

w eve in attendance. 

The aim in prepariw this YepoYt was to summarize the activities of the 

Committee, including its subcommittees, in enough detail to convey 

adequately the considerations that weye weighed in reachi~ substantive 

decisions. Othev background data we~e pvepayed on Committee and subcommittee structuye, basic woyking avyangements, and detailed woyk 

pattemsfoy the consideration of the Committee. All statements and data 

in this repoyt aye cwwent as of Decembev 1964. 

The materials pvesented heve aye awanged in teyms of subject mattey, 

with little emphasis on the contributions of pavticulav individuals OY 

groups. It is obvious, however, that the Committee has been especially 

successji.d in secuving the cooperation of many wovken in many fields, 

whethev to se?we on the Committee itself OY its subcommittees OY to act 

as consultants to either. The overall success of the Committee demonstrates that statisticians and experts in a vaviety of health areas can 

woyk and plan togethey to the mutual advantage of theiv professional inteyests. The institutional forms and pyoceduves that sometimes had 

either to be cyeated OYallowed to gvow in accomplishing this should be 

of inteyest even outside the rather wide boundaries of public health. 
HISTORY OF THE U.S. NATIONAL COMMITTEE


ON VITAL AND HEALTH STATISTICS


John Storck, Ph. D., Division of Vital Statistics 

1. INTRODUCTION 

THE COMMITTEE	 health statistics and othey national agencies. . . . (ref. 1, Recommendation J, p. 21) 

The U.S. National Committee on Vital and 

Health Statistics was established in 1949 by the 

Surgeon General of the U.S. Public Health Serv- BASIC COMMITTEE STRUCTURE 

ice to put into effect a recommendation of the AND FUNCTIONS 

First World Health Assembly. The Assembly 

had acted favorably on proposals of the Inter- In summarizing the achievements of the 

national Conference for the Sixth Decennial Re- Sixth Revision Conference, the official Chronivision of the International Lists of Diseases and cle of the Wovld Health Organization expressed 

Causes of Death that a number of “methods of the view that 

international co-operation in the fields of health 

statistics and vital statistics” be created, in- perhaps the most interesting and far-reaching 

cluding: pvoposal of the confe~ence was that all governments should establish national committees on 

(b) The establishment by the different Govern- vital and health statistics. (Yef. 2, }. 114) 

ments of national committees for the puY- At the same time, only very general guidelines pose of co-ordinuting statistical activities concerning the structure and activities of nawithin the country, and to serve as links be- tional committees had been recommended by the 

tween the national medical-statistical insti- Sixth Revision Conference, including a few sug­ tutions and the Expext Committee on Health gestions of study topics. (See appendix. ) In 

Statistics of the World Health Organization; effect, the membership, organizational structure, 

(c)	 decentralization of studies of certain sta- working methods, problems selected for study, 

tistical problems of public health impor- and methodologies to be utilized were left ~o the 

tance to interested national committees on individual committees. Although such matters 
will be dealt with more fully later in this study, 

some introductory description may be helpful. 

Membership 

Resolution No. 9 of the Sixth Revision Conference had recommended that national committees be “composed of representatives of 

administrations entrusted with the compilation 

of such [vital and health] statistics” (ref. 1, p. 26). 

However it was felt that the interests of the 

United States would best be served by a technical 

committee rather than a coordinating or administrative body. While the Secretary and various 

National Committee members have held official 

positions in the country’s health administration, 

other Committee members, including the Chairman, have not. This has not been the case with 

many other national committees. The U.S. Committee acts formally, however, through the Surgeon General of the U.S. Public Health Service. 

As a principle in selecting the initial membership of the Committee, it was decided 

that membem should not YepYesent organizations OYagenm”es but Yathey that they should be 

chosen to Yepyesent a point of view, an area of 

inteyest, or afield of knowlea(ge essential to the 

cavyying out of the committee’s responsibilities. (Yef. 3, p. 3) 

Structure and Operating Authority 

At the start of its first meeting, the Committee decided that it would perform its functions 

by workiqg through its technical subcommittees and through other committees and organizations. The Committee will not have any authority OY operating Responsibilities and will 

exeycist? its cooydinuti~ function through cooperative effoyt. (Yef. 4, p. 1) 

The quoted passage is only one of a number 

appearing in Committee documents a which state 

a 

Most Committee and subcommittee documents are identified by NC numbers; these numbers have been used in this 

report. 

that the Committee possesses no authority wld 

exercises no operating responsibilities. Some a~;­

pects of this self-denying ordinance will he 

considered in Chapter III, as will the committet Isubcommittee structure. 

The U.S. National Committee constitutes :.n 

interesting experiment in whether a committ~,e 

that carries on its work largely through creatit[g 

subcommittees for special tasks thereby dilutx’s 

or strengthens its capacity for achievement. C:m 

the common weaknesses of committees —indec ision, inconsistency, incomplete handling of prol Ilems, indolence—be overcome by proliferating 

the committee structure? 

Further, can a committee be successful 

that dispenses only work, without funds for doing 

the work and sometimes with only thanks us 

recognition for accomplishing a difficult ar d 

largely anonymous task? 

Statement of Committee Functions 

The Committee and its individual members 

spent a great deal of time and thought in ax -

riving at a suitable statement of the Committee’s 

areas of interest. A draft statement of policy 

and functions had been prepared prior to tk e 

first meeting of the Committee and underwel It 

careful revision, which can be followed in tl-e 

Committee’s files (refs. 3-6). 

The basic purpose was clear: “. . . to guide 

and stimulate studies of technical problems in 

the field of vital and health statistics (interpreted in its broadest sense)” (ref. 4, p. 11. 

By the time the Committee’s first annual repo~t 

was published, the statement of functions had 

taken essentially final form, as follows: 

(a)	 Delineate statistical pyoblemk of publi? 

health importance which aye of nationul or 

international interest; 

(b) Stimulate studies of suchpyoblems by othev 

organizations and agencies whenevey pos ­

sible, OY make investigations of such pyob ­

lems through subcommittees appointed for 

the propose; 

(c) Reviewjindings submitted by othey oygani ­

zations and agencies, OY by its subcomrnit -

tees, and make Yecoinmendations for national an&oY international adoption; 

2 
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(d 

(e) 

Cooperate with othey committees OY organi- tevnational agencies concevned with public 

zations conceyned toith public health sta- health statistics; and 

tistics in the United States so as to seyve 

as a clearinglzouse for activities dealing @ CoopeYate with nationul committees of other 

with public health statistics p~oblems; countries in the study of problems of mutual 

inteyest. (ref. 7, p. 11) 

Seyue as a link between the organizations 

i?t the United States engaged in public health ‘This statement of functions has been reprinted 

statistics and the statistical secretariat of with only slight editorial changes in each annual 

the ?VoyldHealth Organization and other in- report. 

Il. REVIEW OF COMMITTEE ACHIEVEMENTS 

The Committee has usually met twice a year, 

for the most part to consider reports from subcommittees concerning work accomplished and 

to decide on future activities. A typical subcommittee will have met once, though sometimes more frequently, between two Committee 

meetings. A half dozen or more subcommittees 

will usually be working simultaneously, each on 

its own particular problem as assigned to it by 

the Committee. As a rule, no more than one 

subcommittee will be working at any time in 

L1 single area. Sometimes, however, the same 

or a related question may eventually be referred to several groups before a result is 

reached that satisfies the Committee. 

This chapter summarizes the tangible end 

products of activities involving many people, 

without considering how the results were reached, 

or by whom. Although there are exceptions, of 

which some notice will be taken, in almost every 

instance it would be impossible and probably 

futile to allocate personal credit. Obviously the 

Committee’s very considerable achievements 

were nude possible “through cooperative effort” (ref. 4). As a reflection of this fact, and 

in view of the Committee ‘S ultimate official 

responsibility, all final actions of whatever origin within the complex of persons and structures 

here described will be identified as emanating 

from the Committee. 

This chapter will describe 32 Committee investigations, which have been grouped for convenience into the following nine areas of study: 

Number 

Ayea of study of 

studies 

Vital statistics 7 

Morbidity statistics 3 

Hospital statistics 3 

Military health statistics 1 

Classification drafts for ICD revision--- 8 

Fertility and population 6 

Medicolegal death statistics 2 

Quantification of fellness 1 

Health economics 1 

VITAL STATISTICS 

Definitions of Live Birth and Fetal Death 

In 1950 the World Health Assembly adopted 

the following definitions of live birth and fetal 

death, in wording almost identical with Committee recommendations: 

Live biyth is the complete expulsion OF-extractionfiom its mothey of a pyoduct of conception, 

iwespectiue of the duyation of pregnancy, which, 

after such separation, breathes OY shows any 

othey evidence of life, such as beating of the 

heayt, pulsation of the umbilical cord, o?-definite 

movement of voluntary muscles, whethey ov not 

the umbilical coyd has been cut OY the placenta 

is attached; each product of such a birth is considered live boyn. 

3 
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Foehzl death is death pvior to the complete expulsionor extractionpom its mother of a product of conception, irrespective of the du~ation 

of pregnancy; the death is indicated by the fact 

that afier such separation the foetws does not 

breathe or show any other evidence of life, such 

as beating of the heart, pulsation of the umbilical cord, or de>nite movement of voluntary muscles. (ref. 8, p. xm”i) 

These definitions also were adopted by the 

United States as nationally recommended definitions in 1950 and are currently accepted by 

over half of the countr y’s registration areas. 

The previously recommended United States definitions were somewhat less explicit and stipulated 

that at least 20 weeks of gestation was required 

for a stillbirth. The prior international definition of a stillbirth, dating from 1925, ran as 

follows: 

A stiltbirthis the birth of a (viable) foetus aftev 

at least 28 weeks of p~egnancy, in which pulmonary YespiYation does not OCCUY;such foetus 

may die either (a) before, (b) during, OY (c) afte~ 

bitih, but befoye it has byeathed. (Yef. 9, p. 173) 

There is some evidence that users of the 

new definitions have found difficulty in practical 

application of the stated criteria as to “evidence 

-of life,” especially since the phrase is followed 

by “such as . . . “ which suggests that other criteria might legitimately be applied. In addition, 

the criteria themselves have not been generally 

accepted. The WHO Subcommittee on Classification of Diseases therefore has recommended 

reconsideration of the definition at this point 

(ref. 10, p. 16). 

Tabulation of Fetal Deaths 

In submitting the definitions for international 

use, the Committee also recommended that tabulation of all fetal deaths, irrespective of gestation period, k set as a goal; that tabulation of 

fetal deaths of 28 weeks and over gestation be 

established as a bare minimum essential for 

comparabili~ and that fetal deaths (and also 

live births) be &bulated in at least the following 

groupings: 

Less than 20 completed weeks of 

gestation Group I 

20 completed weeks of gestation 

but less than 28-------------- Group 11 

28 completed weeks of gestation 

Andover Group HI 

Gestation period not classifiable 

in above groups Group IV 

In 1962 10 registration areas in the United States 

required fetal death registration for all products of conception, as compared with but 1 

area in 1950. Actual registration remains far 

from complete, although it probably has improved since 1950. Evidence suggests that lowering the age of reporting has increased the completion of reporting in the following gestation 

period. 

Improving Fetal Death Statistics 

Extensive studies were conducted on needed 

improvements in fetal death statistics, based on 

an orientational analysis especially prepared for 

the Committee (ref. 11). Discussion, surveys, 

study of various reporting forms (actual and 

proposed), and field tests were carried out: 

to clarify ways of reporting the causes of 

fetal death; 

to identify obstacles to reporting these causes 

adequately, 

to investigate variations in reporting length 

of pregnant y by alternative definitions; 

to discover what useful information could 

be obtained by matching birth and infant 

death records, etc. 

These studies resulted in a revision of the fetal 

death certificate to make it agree more nearly 

with the birth certificate so far as personal 

particulars are concerned, and with the death 

certificate in requiring a sequential arrangement of conditions related to the death, designed 

to identify the underlying cause of death. The 

Committee nevertheless recognized the obscurity 

with respect to cause that is characteristic of so 

many fetal deaths. 

4 
The 1955 revision of the country’s standard 

certificate of fetal death followed the recommended format in the above respects, but the new 

certificate did not include numerous also recommended checkbox items on conditions occurring 

during pregnancy, labor, and delivery (ref. 12). 

The studies summarized above gave added 

point to the conclusion that the perinatal period— 

the period immediately before, during, and after 

birth—should be approached as a continuum. 

(For later work on the perinatal period, see 

Chapter II, pages 15-16, “Causes Peculiar to 

Perinatal Period.”) 

Occupation Item on Census Schedules 

and Vital Records 

In June 1953 it was decided “to explore ways 

and means of obtaining funds (research grants) 

for studying the comparability between Census 

and birth and death record reports on occupation” (ref. 13, p. 1). A plan, outlined in reference 

13, recommended by an ad /20c subcommittee of 

the National Committee was submitted by the 

Scripps Foundation for Research in Population 

Problems for a Public Health Service research 

grant, which eventually was approved (ref. 14, 

p, 3) 

National Vital Statistics Needs 

In 1951, the problem of defining what was 

indispensable in national vital statistics was 

referred to the Committee, which advised that 

detailed national tabulations certainly should 

be produced for the 3-year period around a 

population census. For other years, localarea tabulations might become primarily a responsibility of the States, and natality data might 

be obtained from a sample of birth certificates. 

It was thought that a level vital statistics budget 

might be desirable, in view of “unpredictable 

difficulties in a cyclical budget” (ref. 15, p. 3). 

For 1951-54, and for 1956 and subsequent years, 

national natality statistics have been based on a 

50-percent sample of registered births. 

Later, after extensive study of the objectives 

and program in national vital statistics, the 

Committee in 1957 published its recommendations. They advised that the agency 

should reject any data pvocz.wement method that 

limits OY restricts the use of vital statistics 

~ecords for reseamh or tkxztprevents it from 

controlling the quality of national vital statistics tabulations. (ref. 16, p. 2.22’) 

Specifically, this meant that data should not be 

obtained in pretabulated forms or through punched 

cards supplied by the registration areas, except 

possibly in a few cases where the punched-card 

method 

can be shown to be mutually advantageous and 

wheve it will not advemely a~ect the scope, 

quality, continuity, and usefulness of nutional 

vital statistics. (ref. 16, p. 223) 

Among the report’s detailed recommendations it was suggested that the agency: 

undertake studies of birth, death, late fetal 

death, marriage, and divorce regismation 

completenesss; 

continue regular efforts to maintain uniformity of classification, completeness, and 

accuracy of reported items; 

consult regularly with data users in planning 

tabulations and publications; 

develop a schedule which releases final data 

to the printer within 15 months of the close 

of the data year; 

strengthen the agent y’s analytical functions 

along directions needed for program planning, administration, and researck 

obtain the budget needed to provide more 

adequate technical services to registration 

areas. 

Need for National Marriage Statistics 

The above-described report as published 

consolidated an independently conducted study 

of the need for marriage statistics with the 

more general analysis of vital statistics needs. 

In addition to outlining the kinds of data needed 

by various types of users, it noted that “strong 

support was expressed for complete national 

5 
and State coverage on an annual basis” (ref. 16, 

p.	 225) and urged the national vital statistics 

agency to “work actively to establish a Marriage Registration Area” (ref. 16, p. 223). This 

area was in fact set up in 1957, just prior to 

publication of the report. On October 1, 1964, the 

marriage registration area included 36 States 

and4 other reporting areas. 

Improving National Divorce Statistics 

After conducting two surveys of consumers 

of published national statistics on divorces and 

annulments, one of researchers anda second of 

other users, a series of immediate and longerrange objectives for the national program was 

developed (ref. 17). Immediate needs included: 

technical help to registration areas through 

more detailed awareness of their special 

situations which would result in their establishing central files of records; 

helping areas to adopt all the standard-record items; 

encouraging research uses of divorce data; 

enlisting the cooperation ofjudges, attorneys, 

court clerks, and their professional organizations. 

Less immediate needs included: 

improving measurement of the completeness 

and accuracy of items on the records; 

encouraging training programs for local 

officials; 

revising the standard record 

expanding the collection of data to other 

legal actions related to family dissolution, 

as well as possibly to desertions and separations. 

MORBIDITY STATISTICS 

Case Registers 

By mid-1949 a Committee-sponsored group 

had distinguished case registers from “various 

types of files, indexes and other collections of 

static records” by the following definition: 

The te~m “registe#’ [should be yesevved for] 

a system of Yecording thatpevmits thepuYposeful collection at regulay intewals of information about the cases included in the YegisteY. 

(ref. 18, p. 2) 

It was noted that such questions were unresolved 

as “the creation of standards relative to the time 

period for follow-up, a definition of the index 

cwe and uniform methods for calculation of 

survival rates” (ref. 18, p. 2). Although the 

question of case registers was referred to another 

subcommittee, it was not actually pursued further. 

Glossary of Terms Used in 

Morbidity Statistics 

At the third meeting of the WHO Expert 

Committee on Health Statistics, in late 1951, 

it was recommended that national committees 

p?’epaye, discuss, and evaluate definitions of 

the terms in cuyrent use in morbidity statistics from the following points of view: 

(1) teyms descriptive of ill health; 

(2)	 terms used to descyibe a particular episode 

of ill health; 

(a) in Yelation topyevious health expe~ience; 

(b) in relation to othey episodes of ill health 

present at the same time; 

(3) te?’ms used to descyibe seveyity; 

(4) teyms usedin measuring dwation of an episode, OY in locating it in time; 

(5) specific teyms used in hospital statistics 

(in addition to those foy moybidity in geneyal); 

(6)	 teyms referring to medical consultation. 

(yef. 19, p. 19) 

In May 1954 the Committee decided to establish “an ad hoc committee to define th~ areas 

in which definitions or a glossary of terms, 

commonly used in morbidity and medical care 

statistics were needed” (ref. 20, p. 3). The 

chairman of the appointed group stated that its 

work would be 
focused on organized medical care pvograms, 

inswra?we plans, etc. . . . tofind out what terms 

people want to have defined, what definitions 

they ave now using and what information and 

cooperation they would like to jlzrnish for nai!ional and international purposes. . . . [Emphasized was] the needfor indexes of measurement 

of social and envi~onmental factors relative to 

kealth. (re$ 21, p. 2) 

For example, occupation as a classification has 

little health meaning, but there is “need for a 

series of indexes of familial status and standards or levels of living” (ref. 21, p. 3). 

Very early it was recognized that actually 

preparing a glossary would require “a full-time 

staff, including some physicians” (ref. 21, p. 3). 

After further investigation, including contracts 

with institutions and organizations to determine 

their needs, it was more explicitly concluded 

that constructing a glossary covering the five 

areas of health personnel, institutional facilities, 

medical and related services, illness and im ­

po.irments, and relevant demographic data 

will be a long, di~cult, and expensive undertaking-, requivin.g a large~ll-time staff for sevcval years. (ref. 22, p, 2) 

It was hoped, however, that a workshop to be 

organized by the American Hospital Association 

might make a start toward initiating a feasible 

project. In its final report the group emphasized 

the need for continuing technical oversight to 

solve problems relating to 

(1) agree v;ent or compromise on definitions, 

(2)	 selection of diffeyent and more specific 

terms for different concepts when agreement or compromise cannot be reached, and 

(3)	 sponsorship and promotion of widespread 

use of glossavy terminology. (ref. 23, p. 2) 

Design of National Health Survey 

Two subcommittees labored briefly and without concrete result on the problem of morbiditv . statistics (refs. 24, 25) b~fore a third group, 

appointed in October 1950, developed a detailed 

statistical design that was instrumental in bringing the National Health Survey into existence. 

Their end result is embodied in Proposal for 

Collection of Data on Illness and Impairments: 

United States (ref. 26). 

The structure of this report faithfully corresponds to the line of investigation which stands 

behind its recommendations. After some introductory matter, Part III deals with “Current 

and Potential Uses of Morbidity and Related 

Data” 

as detenninedfvom the experience of the members of the Subcommittee, from the files of the 

Public Health Service, from the responses of a 

limited number of potential users of morbidity 

data who were questioned by members of the 

Subcommittee, andfrom other sources. (ve$ 26, 

p. 7) 

It was found, and details of need were supplied 

in each instance, that morbidity and related statistics were required for 

administrative planning and evaluation of 

health programs; 

determining current health needs for medical 

and dental service, facilities and personnel; 

suggesting hypotheses and providing other 

aids to medical research; 

determining manpower needs; 

estimating markets for manufacturers of 

drugs and appliances; 

supplying statistics for public health education programs. 

Upon the basis of this inventory of needs, 

Part IV of the report considers “Types of Data, 

Detail, and Frequency of Collection Required. ” 

The following general statement governs the 

findings of this section: 

A minimal adequate program to provide statistics .foy the uses listed M Part III would necessitate collection of data of nationul scope on incidence, prevalence and the duration of disability 

for the major categories of disease and impairment. The data should allow subclassification 

by sex, by several age groups, and by employment, educational, income and occupational sta7 
tus, and should have sufficient regional geographic detail to be usable by the Health Officers 

of States or cities. (ref. 26, p.9) 

It was recognized that some of the needs developed 

in Part 111 “would require specialized studies 

which have little relation to one another or to a 

national program of data collection” (ref. 26, p. 

lo). 

The problem of estimating the need for 

medical care was discussed in an appendix which 

outlines three possible methods for getting such 

data that seemed to be worth further study: 

(1) by expert appraisal of needs; (2) by study 

of services being obtained under favorable conditions now existing; (3) by collecting evidence 

regarding shortages of services and facilities 

(ref. 26, pp. 22-23). 

Part V of the report surveys present sources 

of national morbidity statistics. Included is a 

summary of advances in sampling and survey 

techniques since the earlier National Health 

Survey. The results of this study were still 

being used in the fifties because later national 

data were lacking, in spite of these improvements, great demographic changes, and fundamental alterations in the country’s morbidity 

patterns. Consideration of a variety of new but 

relatively limited sources of morbidity data led 

to the conclusion: 

It is not possible to fill the ur~ent needs for 

nutiond statistics on the incidence and prevalence of diseases, injuyies, and impairments 

and on the utilization of medical seyvices by Yelying solely upon records now being collected 

OY data ewwently available. (Yef. 26, p. 16) 

It was therefore recommended “that a continuing national survey be conducted, adequate 

to provide regional estimates at intervals of two 

years and estimates for the nation as a whole at 

quarterly intervals” (ref. 26, p. 18). It was 

further recommended that this survey obtain 

its information from a probability sample of 

households, for which the report then developed 

concrete statistical specifications. 

Since the household survey would be based 

on lay responses of experienced morbid conditions, the report also recommended “special 

studies . . . to obtain data on undiagnosed and non -

manifest diseases by means of physical examina ­

tions of a sample of the U.S. population” (ref. 26, 

p.	 21). It was foreseen that this might involv ? 

“mobile examining units, publicity campaigns, 

special transportation for examinees, etc. ” (rel, 

26, p. 21), since the sample could be considere ~ 

representative of the population only if a larg ? 

proportion of the selected individuals was actually examined. Other special studies would 

focus on methodological problems and evaluation~. 

On July 3, 1956, President Eisenhower signed 

the National Health Survey Act, Public Law 652, 

84th Congress, empowering the Public Health 

Service to make studies to determine the extert 

of illness and disability in the population of the 

United States and to gather related information. 

To October 1964, 88 reports had been published 

based on information from the household interview and health examination surveys which came 

into existence by virtue of this law. 

HOSPITAL STATISTICS 

Community’s Need for Hospital Statistics 

At its first meeting the subcommittee nmmbers were asked “to obtain viewpoints on the 

orientation of International Statistical Classifica ­

tion to hospital use and on uses of hospital morbidity statistics” (ref. 4, pp. 2-3). Study of both 

matters was started early in 1950, but a concrete result was first obtained on the second 

topic. Attention was addressed in part to tle 

intriguing question of using hospital information 

“to provide data with respect to morbidity in the 

community” (ref. 27, p. 10). It was recognized 

that the community needs data of much the same 

kind as does the individual hospital, including 

information on the kind and quantity of available facilities. The community also needs information on the relative importance of various 

factors that influence the use of hospital facili -

ties, which can best be obtained through special 

studies that take account of the existing soci:d 

machinery and general social purposes of tl-e 

community. It was also suggested, hOWeVe]”, 

that hospital data might throw light on tke 
occurrence of disease in the community in two 

other ways: 

a.	 Certain diseases, such as multiple sclerosis, 

show very high hospitalization rates, and thus 

may be studied directly from hospital records. 

b.	 Hospital data might be combined with other 

data to form a picture of the extent of illness in the community: 

Tlte pt-oblem heve is one of methodology—of 

determining how the seveval types of data may 

be co]nbined. It is essential to the development 

of such methodology that studies be designed to 

hri)zg out the ~elationship of hospital data to 

otlw~ sources of information on illness in the 

gemwal population, such as the household suYwy, industry, the schools, the physicians of the 

colnnmnity, etc. (Yef. 27, p, 16) 

The same idea had been expressed over a year 

earlier in a footnote added by the WHO Expert 

Committee on Health Statistics to the report of 

the first meeting of its Subcommittee on Hospital 

Statistics, which was held in April 1950: 

. . . the Expevt Committee on Health Statistics 

Stvesses the need fov investigating methods ad 

possibilities of bvid~”ng the gap between Jzospital statistics and statistics representative of 

the community from which the patients of the 

ltospital are dvawn. TJze committee believes that 

tilefamily type of swwey OY the complete cove~­

agt? of medical-care seyvices might offev the 

means of opening hospital statistics to broader 

i?de~pretation and of enhancing theiv use@lness 

jbY public haulth-puvposes. (Yef. 2S, p. 31) 

The Expert Committee returned to the idea at 

its third meeting, in November 1951, when it 

suggested that “sub-samples of hospital records 

random with reference to the general population” 

could be studied to adjust biases in the hospital data (ref. 29, NC dot., p. 15). 

A 1953 article (which WHO has translated 

into French and Spanish) based on the Committeeinitiatecl studies considers ways in which infornmtion from cases treated in hospitals might 

be used to study community morbidity, as for 

example by using morbidity surveys to find 

out how the hospital data would have to be 

udjusted to apply to the community (ref. 30). 

Adaptation of ICD for Diagnostic Uses 

The 1949 interest of the National Committee 

in the possibility that the International Classification of Diseases (ICD) might be used to code 

diagnoses followed hard upon the 1948 Sixth 

Revision introduction of usually nonfatal disease categories into the list so that it could be 

used for morbidity coding. In 1950 the Veterans 

Administration and the Public Health Service 

Hospital in Baltimore started tests of the classification for hospital indexing, while the ColumbiaPresbyterian Medical Center in New York City 

modified the list for the same purpose a year 

later. Already by early 1950 use of the classification for diagnostic purposes had gone so far 

that WHO thought it necessary to offer recommendations on how variations from the ICD 

should be indicated (ref. 28, p. 35). 

Previously, hospitals had used either lists 

of their own making or made-do with the Standard Nomenclature of Diseases and Operations 

(ref. 31). This work lists essentially every recognized term regardless of its frequency of use. 

An adaptation of the ICD was developed under 

the coordinating leadership of the Committee, 

and a study of its effectiveness in diagnostic 

indexing was initiated in 1956 by the American 

Hospital Association and the American Association of Medical Record Librarians, with financiaI 

support from the Public Health Service. The 

study showed that coding and posting were faster 

with the adaptation than with the Standard Nomenclature, and that more pertinent records were 

found in answering requests (ref. 32). On this 

basis major users of the adaptation cooperated to 

develop a uniform modification of the ICD for 

hospital indexing, using the Seventh Revision 

(1955) as a base (ref. 33). An operation and 

treatment classification also was produced. 

Most of the changes from ICD listings in the 

diagnostic code are confined to adding fourthdigit codes to gain greater specificity. This 

involved renumbering some of the ICD’S fourthdigit subdivisions. For the most part three-digit 

codes were not altered, but in some cases terms 

were transferred from one three-digit category 

to another so that they would conform to usage 

in American hospitals. The major area where 

comparability is not maintained is the section 

9 
on “Mental, Psychoneurotic, and Personality 

Disorders, ” where the 1952 diagnostic code of the 

American Psychiatric Association was used because it is accepted by American mental institutions. Residual categories such as “Injuries 

of Other and Unspecified Nature” were eliminated, 

as were combination codes (such as “Measles 

with Pneumonia’ ‘), and classifications depending 

entirely on sex, age, occupation, or type of 

operation. In addition the external-cause listing 

of injuries was sharply reduced (ref. 33, vol. I, 

pp. iii-v). 

Hospital Statistics and the 

National Health Survey 

In 1957 the Committee decided to study what 

kinds of hospital data the recently established 

National Health Survey might collect for hospital use, and also the kinds of data that hospitals might produce for the survey. By late 1959 

a report including a number of recommendations 

had been prepared and was transmitted to the 

National Health Survey and the American Hospital Association. Included were indications of 

data needed on both in-patients and out-patients. 

Some of the recommendations in this report 

probably now need review in light of the fact that 

a Division of Health Records Statistics has been 

established in the National Center for Health 

Statistics. Other recommendations were concerned with the types of information that States 

and communities might collect, for the most part 

so that they might be obtaining data comparable 

to that recommended for collection by the National Health Survey (ref. 34). 

MILITARY HEALTH STATISTICS 

In 1948 the First World Health Assembly 

recommended that Canada and the United States 

adapt the ICD to the needs of the armed services 

(ref. 1, Recommendation No. 9, 7(b), p. 26). 

The Committee entered into cooperation with 

representatives of their Canadian counterparts, 

the Medical Advisory Committee to the Dominion 

Statistician, using Army, Navy, and Air Force 

experts who had been working on an adaptation 

for the Department of Defense as members of 

its own group. A draft adaptation of the extemalcause-of-injury code (E code) was prepared and 

submitted to WHO. This classification (ref. 35) 

was circulated by WHO; comments on the classification are given in reference 36. At the Seventh 

Revision Conference it was decided that this 

classification did not meet the needs of all 

countries, and it was recommended that a list be 

developed “which would be sufficiently detailed 

for the needs of the armed services, capable of 

conversion to an abbreviated list . . . as well as 

to the three-digit categories of the E code of the 

International Classification . . . “ (ref. 37, pp. 

14- 15). Subsequently the Department of Defense 

and the British War Office prepared a further 

adaptation of the E code which was accepted 

by the armed forces of both countries and alsc 

was submitted to WHO for trial use (ref. 38). 

In 1954 the Committee also submitted recommendations to WHO on minimal tabulations oi 

military health statistics designed to permit international comparisons (refs. 39 and 40, p. 2). In 

1959, further modifications were made to develo~ 

a draft revision which would be suitable both for 

use in the United States and as a draft proposal 

for further international discussion. A representative of the British War Office participated ir 

the development of this draft classification whict 

was completed early in 1961. The classification 

was accepted for use by the Armed Forces of tht 

United States and by the Armed Forces of tht 

United Kingdom and submitted by the Committee 

to WHO in 1963 (ref. 41, p. 2). 

CLASSIFICATION DRAFTS 

FOR ICD REVISION 

In this section, classification proposals for 

the Eighth ICD Revision emanating from the Committee will be taken up in the order of the chapters to which the diseases involved principally’ 

belong in the Seventh Revision. The names of tht 

section subheadings, however, will agree substantially with names proposed by the Committee 

as follows: 

Mental disorders


Cardiovascular diseases


Congenital defects


Causes peculiar to the perinatal period


10

Accidents, poisonings, and violence (E code)


Accidents, poisonings, and violence (N code)


Physical impairments


Operations and treatments


Mental Disorders 

The WHO Subcommittee on Classification 

of Diseases made note of several criticisms of 

Section V of the ICD: 

the title of the section— “Mental, Psychoneurotic, and Personality Disorders’ ‘—is misleading; 

many organic mental disorders are classified 

elsewhere, or not at all, while categories are 

lacking to accommodate diagnostic terms in 

curent use; 

the category “Mental deficiency” confounds 

dugree of lack and etiology, in addition to 

inadequate coverage of specific types of deficiency (ref. 10, pp. 20-21). 

There is a further difficulty in arriving at an 

international classification in that psychiatrists 

of different countries do not agree on diagnosis 

and terminology. In the United States the 1952 

classification of the American Psychiatric Association is generally followed by mental institutions. 

In mid-1961 a listing substantially identical 

with the Association classification was submitted 

as a working document to WHO and to the United 

Kingdom group working on mental disorders. b 

WHO then had at least seven classifications to 

cunsider, concerning which it hopefully reported 

“substantial agreement. “ It was noted, however, 

that the United States proposal involved 

distinguishing whether “organic brain syndromes” - disorders associated with known 

factors acting on brain tissue (infections, 

b 

The American Psychiatric Association classification as 

edit.ed by tho Committee (and including the 1959 classification 

of mental retardation of the American Association on Mental 

Ddiciency) is contained in an unnumbered Committee document (ref. 42) which was accepted for submission t6 WHO 

“for discussion purposes” (ref. 43, p. 3). The classification 

NH edited by tbe WHO Subcommittee on Classification of Disuuscw is found in reference 44. 

drugs, etc. )—were accompanied by psychotic 

reaction or by other mental disturbance, the 

two being separately coded 

coding the etiologic factors associated with 

organic mental disorders, and likewise the 

organic factors associated with mental deficienc y; 

using many terms not commonly accepted elsewhere (as “psychophysiologic” rather than 

“psychosomatic”; ‘‘antisocial’’—and also “dissocial’ ‘—”reaction” rather than “psychopathic 

personality”; also general use of “reaction” 

where other psychiatrists would use a variety 

of terms); 

including some classifications based on age 

distinctions. 

(This last is noted in reference 10, p. 23). 

In September 1962 a joint United Kingdom 

and United States meeting in London resolved 

most of the above (and yet other) difficulties 

(ref. 45); in September 1963 a preliminary meeting of eight nations on the classification of 

mental disorders was called by WHO and produced yet another list (ref. 46); and thereafter 

the United States recommended a few changes 

in the resulting draft. (ref. 47; differences between the United States and WHO drafts can be 

identified by referring to the notes on p. 5 of 

this reference. ) At a meeting held late in 1963, 

the WHO Subcommittee on Classification of Diseases made recommendations concerning two 

main points of still outstanding difference, decided to circulate the latest American proposal, 

and itself recommended a number of relatively 

minor changes in the classification (ref. 48, pp. 

18-19). 

At its late 1961 meeting the Subcommittee 

on Classification of Diseases strongly endorsed 

a proposal made by the WHO Expert Committee 

on Mental Health, in its first and eighth reports, 

that a glossary of terms, with descriptive definitions, be compiled that would be applicable to 

categories in the new classification (ref. 10, p. 

21; refs. 49 and 50). At its late 1963 meeting the 

subcommittee took note of a glossary drawn 

up in the United Kingdom, which has been circulated as an example of the definitions given 

to psychiatric terms in one country (ref. 51). At 

11

its 1961 meeting the subcommittee looked far 

ahead to the eventual preparation of a comprehensive monograph on psychiatric terms which 

would take account of “the differences in general 

conception and symptomatology in different 

schools and parts of the world” (ref. 10, pp. 21-

22). 

Regardless of the ultimate outcome in the 

way of a revised classification of mental disorders for the Eighth Revision, the work that was 

accomplished over these half-dozen years at the 

national and international levels in a problemstudded area offers a splendid example of the 

strength and versatility of the system that links 

national committees and technical WHO groups 

into a powerful force for improving the statistical 

data on which so many of the efforts in public 

health must rest. 

Cardiovascular Diseases 

The effort to work out a satisfactory cardiovascular disease classification faced in heightened 

form very much the same difficulties that had 

been encountered in the case of the mental-disorder classification, along with other special 

problems. Very similar efforts toward cooperation, starting from different empirical and theoretical backgrounds, were engaged in over a halfdozen years between the United Kingdom, the 

United States, and WHO committees. 

The problem is given great urgency by virtue 

of the fact that in cardiovascular and closely 

related conditions medicine and public health 

are faced by a great and still largely mysterious 

disabler and killer. Chapter VII of the Seventh 

Revision of the ICD, “Diseases of the Circulatory System, ” by itself accounts for about 40 

percent of all deaths in “developed” countries. 

A health examination administered to a probability sample of the noninstitutionalized, civilian 

population of the United States between October 

1959 and December 1962 indicated that 13.2 percent of the country’s population aged 18-79 years 

had definite heart disease, while an additional 11.7 

percent showed indications of suspect heart disease. At ages 65-74 years 39.9 percent showed 

definite heart disease, while an additional 20.7 

percent showed suspect heart disease. At ages 

75-79 years these percentages were 42.3 and 

25.2, respectively (ref. 52, table 1). 

Although much is known about the bare 

phenomena associated with cardiovascular-renal 

morbidity and mortality, the etiology of the known 

phenomena and indeed often even their manner 

of relationship still remain obscure. How does 

the concept of underlying cause that is used for 

coding deaths fare in this situation? The ICD 

Seventh (1955) Revision cardiovascular classification was taken over substantially unchanged 

from that in the Sixth (1948) Revision which was 

somewhat outdated even then. In discussing “the 

large group of degenerative vascular conditions 

manifesting themselves as hypertension, arteriosclerosis [i.e., conditions substantially similar 

to what is now called atherosclerosis], cardiac 

and renal affections or lesions of the central 

nervous system, ” the Manual of the International 

Statistical Classification of Diseases, Injuries, 

and Causes of Death, Based on the Recommendations of the Seventh Revision Confe~ence, 1955 

(Seventh Revision Manual) states: 

It is concedes that the avrangenzent in the Classification is artificial and difficult to apply, involving refevence to numerous notes and instructions. The present amangement, however, 

was adopted at the sixth revision as a compromise betweengivinghypertension its dwe weight 

as an etio.logical factor and providi~ contirzwity 

with previous statistics. (~ef. 8, p. xxxi) 

According to criteria recommended by the American Heart Association, identification of cardiovascular disease requires a four-fold diagnosis: 

etiological basis; anatomical or structural 

changes involved (as thrombosis, active m yocarditis); disturbance of cardiac physiolag y or 

the patient’s s ymptomatology; and functional and 

therapeutic classification (ref. 53, p. 492). The 

last would not be appropriate in the present 

situation. 

Two solutions of the cardiovascular classification problem appeared to be possible, each 

calling for a fundamental, but different, revision 

of the classification for cardiovascular-renal, 

and possibly also for diabetic, conditions. One 

might code combinations of conditions as derived 

from the death certificate, or one might code 

12 
substantially each condition identified on the 

certificate and thereafter produce desired combinations (“multiple causes’’) through tabulation. 

Both these procedures, however, assume that 

medical certifications can be translated into statistics in these ways without substantial distortions, Do most physicians fill out certificates 

in about the same degree of detail? Do they organize their responses with a satisfactory degree 

of uniformity according to the steps laid out in the 

medical certification, as it appears below? 

18. CAUSE c2F DEATH (Enter only one cause per line for (a), (b), 

and (c) 

PART 1. DEATH WAS CAUSED BY: 

IMMEDIATE CAUSE (a) 

Conditions, if any, DUE TO (b)


which gave rise to


ahovc cause (a),


stating the under-


lying caum last. 1 DUE TO (C)


PART Il. OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH 

BUT NOT RELATED TO THE TERMINAL DISEASE CONDITION 

GIVEN IN PART I (a) 

I 

Of the two solutions, one was exemplified 

by the Statistics Section of the American Public Health Association, and the other by Dr. 

Harold’ F. Dorn, Chairman of the National Committee’s Subcommittee on the Classification of 

Diseases; while in a series of meetings that 

began in August 1962 the United I<ingdom and 

United States experts attempted to find a common ground between them (ref. 54). The APHA 

committee favored “combination categories. ” The 

first of its six recommendations advised, for 

the Eighth Revision, that “consideration be given 

to the fuller development of a disease-complex 

type of classification” (ref. 54, APHA, P. 78). 

While the committee also advised study of the 

multiple-cause problem, it noted several difficulties standing in the way, among which the 

most important probably are “a satisfactory y 

description of the specific disease categories 

to be classified for the desired statistical purposes” (ref. 54, APHA, p. 75) and the present 

medical certification form. 

There appeared to be relatively little disagreement as to the nature of the problem in 

need of solution. For years, the underlying 

cause concept had served the purposes of mortality statistics well in delineating the principal 

mortality problems. However, with the increasing 

proportion of deaths from the chronic diseases, 

the underlying cause concept had become less 

and less adequate in describing the diseases 

involved in the causation of death. The solution 

to this problem was to make available more 

information on disease complexes. 

There are two ways of accomplishing this. 

One is to build into the disease classification 

itself the various combinations of diseases that 

are desired. The objections to introducing a 

large number of cross-classifications into the 

International Classification of Diseases were 

summarized as follows by Dr. Harold F. Dorn. 

It in.te~fe~es with the vayious uses . . . such as 

a medical indexi~ in hospitals and in obtaining 

a total count of conditions. . . . 

Only a limited numbe~ of combination catego~ies 

can be provided foy in the classification. . . . 

It would not be possible to anticipate future 

needs, 

Intvoduci~ ~igidity into the classification which 

will be frozen fov the period of its use. . . . 

Designing a disease classification to yield information which should noymally be obtained in 

tlze tabulation procedure. (ref. 54, Dorn, p. .0 

Dorn proposed a second solution, that an 

unduplicated list of diseases be adopted for a 

disease classification, and that multiple diagnoses be coded. The association of diseases 

could then be established in the tabulation stage. 

This approach avoids the technical objections 

to introducing combination categories into the 

disease classification. 

While there was agreement in principle to the 

desirability of coding multiple diagnoses, it was 

felt that not many countries would be able to 

undertake routinely the coding and tabulation of 

multiple causes of death. 

In view of this situation, the U.S. and U.K. 

groups adopted the position of admitting a limited 

number of combination categories. With respect 

to combination categories, the representatives 

of the U.S. and U.K. groups met in London on 

August 28-29, 1963, and reached an agreement 

(ref. 54, U.K.-U.S. documents) which included 

the following. items: 

(1)	 The inc~eased reporting of combinations of 

diseases complicates the direct use of the 

13 

I 
(3) 

(4) 

underlying cawse principle in compiling 

medical statistics, and makes necessary the 

use of combinations of disease categories 

in cases where it would be meaningless to 

select one among the conditions reported. 

. . . . . 

These combination categories should always 

be made up of conditions ?’eceivingindepe?uient numerical recognition elsewhere in the 

classification. This would ensure that tabulation of the categories could be achieved 

eithey by pyimayy coding to them OY by compilation from theiy constituent elements. 

. . . The combination categories should be 

distinguished in the ICD in some way fyom 

the conditions of which they weye made up. 

In regard to the cardiovascular disease 

classification, it was suggested that hypertension 

should receive more definite recognition, with 

nine three-digit categories allotted to its more 

important combinations with other cardiovascular 

conditions. 

The U.S. National Committee accordingly 

forwarded a classification to WHO in October 

1963 which provided 10 three-digit codes in one 

block for combination categories involving hypertension and various forms of heart disease 

and cerebrovascular diseases. 

The WHO Subcommittee on Classification of 

Diseases “agreed in principle that the ICD should 

be so constructed as to allow any country to 

demonstrate associations either by multiplecause coding or by direct coding to combination 

categories” (ref. 48, p. 12). At the same time, 

the subcommittee gave little guidance to the 

WHO Secretariat in choosing combination categories: “The particular combinations which would 

be desirable in the ICD would be decided when 

the individual sections were revised” (ref. 48, 

p, 12). 

Congenital Defects 

When consideration of Chapter XIV of the 

Seventh Revision, “Congenital Malformations,” 

was begun in late 1961, it was known that the 

existing list was incomplete: 

The pyesent classification includes only malformations OY structwal changes and does not 

cove?’ impoytant congenital anomalies which aye 

now classified elsewheve. A moye inclusive 

classification is needed to include all manifestations of disease, whether based on clinical 

observations OY on laboyatoyy tests, zvhich aye 

pyesent at biyth OYpyesumed to be pyesent at 

biyth and concerning which there is no indication that the condition was acquiyed duying OY 

afier biyth. It was Recognized that it would not 

be practicable to include all diseases or conditions which have some genetic backg?vund (e.g., 

diabetes mellitus), but that an effo~t will be made 

to hying togethey the impoytant defects whicJl 

have a faiyly cleay-cut genetic base. (Yef. 55, 

p. 1) 

Accordingly, it was decided at an early stage 

to include not only gross anatomical genetic defects, but also congenital cellular defects recognizable chiefly by microscopic examination and 

congenital defects due to inborn errors of metabolism (ref. 56, p. 1). The subcommittee eventually 

called its list a classification of “congenital 

defects.” 

The resulting draft was submitted to interested agencies, including vital statistics offices, maternal and child health groups, crippled 

children’s programs, hospitals working on related studies, and other concerned groups and 

individuals (ref. 57). Comments on the draft 

are given in reference 58. In October 1963 a 

slightly revised version of the classification was 

sent to WHO (ref. 59, p. 3), although it was 

recognized that a number of changes in the 

classification were probably desirable: 

Question was Yaised as to the appyopriatenoss 

of including the congenital hernias in this section since it would be difficult to determine 

whethev they weye congenital ov acquiyed. . . . 

It was also suggested that the subcategories for 

congenital tumors be transferred to the section 

on neoplasms. Recommended also was the deletion of the teym “EndocaYdial fibyoelastosis” 

fyom the section on congenital heayt defect . . . 

because not all such conditions are congenital 

in oyi~”n. 

14 
Lack of specificity of cevtain catego~ies, defects of ovgans or orga~ systems was noted (e.g., 

ckondvodystyophy, congenital Jtypertrophicpy ­

lovicstenoses, etc., wkichare identifiable categories in the Seventh Revisioti. It was suggested tkat ce~tain specific subcategories be 

accommodatedin the space vacated by the suggested deletions and Wansfers. (vef. 60, p. 1) 

When the WHO subcommittee met to consider 

the accumulated revision proposals 

discussion . . . tended to favow a mixtrwe of 

tkc United States and United Kingdom classifications, wkick would retain the detail of the 

United Kingdom classification of stvuctwal 

abnormalities with the addition of the metabolic 

and cellular defects as proposed by the United 

States Oj-AmeYica. . . . Howevev, it was Yealized tkat tke nwmbev of cate.govies would have 

to be incveused to make this possible. It was 

~ecommended that if this expansion were not 

possible, the congenital metabolic defects should 

be classified with the other metabolic disorders 

in order to presevve the detail of the United 

I<in,gdom proposal in respect of the gvoss malformations. (ref. 4S, p. 26) 

Another WHO document (ref. 61), comments on the 

implications that transfer of inborn errors of 

metabolism to congenital defects would have 

elsewhere in the list. 

Causes Peculiar to Perinatal Period 

The early interest of the Committee in the 

problem of fetal deaths led to efforts in two 

directions. First, since “it is estimated that the 

present magnitude of the fetal death problem is 

as great, if not greater, than that of infant 

deaths at the turn of the century” (ref. 62, p. 1), 

the Committee saw the need for 

establishment of a continuing committee unde~ 

a bvoade~ sponsoWtip than can be p~ovided by 

t}w National Committee to promote and coordinate activities fov the prevention of repvoductioe wastage. Suck a committee should have 

representation from the fields of obstetrics, 

pediatrics, patkology, hospitals and statistics. 

(ref. 62, pp. 1-2) 

In considering how to improve fetal death registration o.nd other supposedly limited questions, 

study groups were continually forced, on the one 

hand, into consideration of causal factors, and on 

the other felt the need to move across the dividing 

boundary of birth. A subcommittee was established 

in June 1956 with the following extremely broad 

charge: 

To Yecommend a method of classifying causes 

of fetal deaths as reported on vital and hospital recoyds; 

to review existirg classifications of causes of 

fetal deaths and cawses of neonutal deaths; 

to develop a satisfactory classification a~er 

studying the inte?zvelationships of existing classifications; 

and to determine the need fov a nomenclature 

to use in vepovting fetal deaths. (vef. 63, p. 17) 

Experts in the United States were not alone 

in reaching the conclusion that the period immediately before, during, and just after birth forms 

a continuum that should be bridged statistically. 

The following action, for example, was taken at 

the Seventh Revision Conference: 

The Conference endomed the proposals of the 

Expert Committee in respect of studies to sevve 

as a basis fov the imp~ovement of the present 

classification of cawses of stillbirths and of its 

application, namely: 

(c) studies aimed at compavi~ and integrati~ 

the Yeported causes of foetal deaths and deatks 

duying the neo-natal peviod. (Yef. 37, Conclusions (a) I 1.5, p. 7) 

Over several meetings the experts pressed 

forward in many directions, while increasingly 

directing attention on a workable classification. 

It was early decided to confine the classification 

“to diseases and causes that were peculiar to the 

reproductive process” (ref. 64). 

In June 1957 the National Committee “suggested . . . action on a definition of the perinatal 

period” (ref. 65, p. 2). Not until September 1960 

did the Committee receive a definite reply, and 

that was a recommendation, not of a definition 

the subcommittee itself had devised, but of the 

1959 definition of the American Medical Association’s Committee on Maternal and Child Care: 

I.	 Perinatal Peyiod I as a minimum basis for 

achieving nationwide as well as intenaational 

15 
comparability, wilt begin with deaths of fetuses weighing 1,001 gvams (28 weeks gestation) and include deaths of infants occuYYing in the first 7 days of life. 

u Pen-natal Period IIfor more inclusive study, 

and recommended whenevey possible, will 

begin with deaths of fetuses weighitg 501 

grams or more (20 weeks gestatiord and include deaths of infants occur~ing in the jinst 

2S days of life (full neonatal peyiod. (ref. 

66) 

By June 1958 a draft classification excluding 

congenital malformations (which were eventually 

turned over to another group of experts) had 

been prepared for what was called a pretest on 

mortality records. (ref. 67. This draft was 

supported by various coding materials, references 68-72. ) After some modifications, the revision was tested on morbidity data from a dozen 

or so hospitals, leading again (ref. 73) to a revised draft which is given in reference 74. By 

this time it had been decided that the classification 

should be titled “Certain Causes of Morbidity 

and Mortality Peculiar to the Fetal and Early 

Infancy Periods. ” Some additional comments 

(ref. 75) led to the final revision (ref. 76) 

which was accepted for submission to WHO. 

The resulting classification of the perinatal 

period has the following general characteristics: 

a.	 It completely eliminates all fourth digits 

for immaturity. 

b. It emphasizes certain conditions, as 

distinguished from causes, as for example birth injuries, difficulties of labor, 

maternal state during pregnancy or 

labor, conditions associated with asphyxia or hypoxia (anoxia). 

c.	 It eliminates all age categories, as for 

pneumonia and diarrhea, although there 

is a three-digit code for infections 

acquired before or during birth. 

In considering the classification the WHO Subcommittee on Classification of Diseases observed: 

It is not a self-contained list for classification 

of all causes of perinalal morbidity and mo?’-

tality without reference to the othey sections of 

the ICD and it will lead to a disruption in the 

historical trend of statistics of cawses of stillbirth. 

The Subcommittee considered whethe~ the classification of perinatal cawses should be a separate list or whethey it should be an integral pavt 

of the mainICD classification. The general opinion favouyed integration. (ref. 10, p. 14) 

The subcommittee accepted the proposal as a basis 

for further study, and recommended “that WHO 

work out the detailed implications of bringing the 

perinatal list into the general ICD” (ref. 10, 

p. 15). 

Accidents, Poisoningsr and 

Violence (E Code) 

Since the Sixth Revision of the ICD (1948), 

the list has included a dual classification of 

accidents, poisonings, and violence, according to 

external cause (E code) and according to nature 

of injury (N code). Each section provides for 

adverse reactions to prophylactic inoculations 

and therapeutic misadventures. With respect to 

accidents occurring while at work, the Seventh 

Revision Manual made this recommendation: 

AS far as p~acticable, occupational accidents 

should be tabulated separately under each category of both the E and N classifications. Occupational accidents may be conveniently defined 

as all injuries and poisonings to gain.lly employed persons while at work. “Gain&lly employed” includes self-employed. . . . Accidents 

to peysons whose occupation is directly connected with the cause of injuyy, even though unspecified that the peyson was at wo~k at time 

of in.uyy, are to be tabulated as occupational accidents. HoweveY, othey definitions may be used, 

depending on the source OYpuypose of the statistics. Fov this Yeason, it is tmpo~tant that the 

definition used be specifically stated. @cf. 8, 

p. 243) 

As the WHO classification subcommittee 

noted in late 1961, however, while reviewing the 

E list, accidents occurring in industry “at present 

lack sufficient specific categories” (ref. 10, 

p.	 26). Thus E912, Accident caused by machinery, 

includes a listing of 45 types of machine under 

this undivided rubric, from binder through electric 

fan and on to pile driver, roller coaster, and 

finally washing machine. Nor, in many instances, 

were more than a few of the 10 fourth-digit 

codes identifying the place where the accident or 

16 
poisoning occurred really applicable tothe threedigit rubrics fornontransport accidents to which 

they were intended to apply. 

In its examination of the Seventh Revision E 

code, the WHO subcommittee also noted that it 

devotes a ~elatively la~gep~oportion of its cate ­

,goYiw to Watisport accidents. . . . Mo~eove~, 

it was Pointed out tkat it was difficult in certain countyies to obtain f~om the medical cevtifie~ adequate information on the ci~cumstances 

of the t~anspo~t accident to allow proper classification in the E section. (vef. 10, Pp. 25-26) 

Yet in a country like the United States deaths 

from motor vehicle accidents constitute about 

40 percent of all accidental deaths. This is 

double the number of deaths due to accidental 

foils and about 15 times the number of deaths 

due to accidental poisonings, which are other 

categories showing a considerable number of 

deaths. 

In almost any country, accidents figure 

among the more important causes of death. In 

the United States, for example, accidents alone 

(without suicide and homicide) were the seventh 

most frequent cause of death in 1900 and the fourth 

most frequent cause in 1963, although the death 

rate for accidents had been reduced from 72.3 

to 53.4 per 100,000 population over these years 

(ref. 77, p. 452; ref. 78, table 1-8). Accidents 

account for about half of all deaths for the age 

group 5-24 years in the United States. During 

the 4-year period ending with June 1961, about 

one out of eight acute conditions (acute illnesses 

and injuries) experienced by the noninstitution ­

idized, civilian population of the United States was 

an injury, and each 100 such persons experienced 

an average of 27.8 injuries per year (ref. 79, 

pp. 4-5). 

After a preliminary draft of an E code had 

been developed by the American experts, it was 

tested through coding of 4,000 deaths and 60,000 

cases of nonfatal injury. A revised version then 

was sent to State health departments and agencies 

concerned with accident prevention, after which 

the classification underwent another revision, 

and thereafter a few final changes. In this classification, which was forwarded to WHO by the 

Nutional Committee in October 1963, the previously mentioned 10 fourth-digit codes identifying 

place of occurrence of the accident were given 

up: “The Subcommittee had considered this problem and elected to utilize the subdivisions for 

specific items which it considered more useful 

for accident prevention purposes” (ref. 80, pp. 

2-3). Many of its proposed fourth digits pertained 

to place of occurrence, but others covered manner 

of injury involved, nature of the injury, etc. 

WHO had received another proposal for complete revision of the E code from the United 

Kingdom, which 

set out to incorporate into the ICD a series of 

categories fov industrial accidents which would 

be compatible with the International Labour 

Office (IL O) classijlication [International Labour 

office Official Bulletin, Vol. 46, No. 1, 1963], 

using two axes of classijZcation accordi~ to 

type of accident and agency, though not at the 

sac~ifice of necessary detail for mm-industrial 

accidents. (ref. 48, p. 29) 

The WHO subcommittee found that 

the United States proposal was designed to produce the maximum information wseful for measures of gene~al accident Jwevention, going into 

great detail, for example, in respect offires 

and jWls. . . . 

The Sub- Committee considered the amount of 

detail desiyable in the ICD. As a classification 

foy geneyal puyposes, it could not. convey the 

type of information required for highly specialized investigations. . . . On the other hand, this 

section was the only source of large-scaJe statistics on accidents and ought peyhaps to pYovide for all the detail likely to be available in 

the sowce documents. . . . 

The question of identifyi~ occupational origin 

. . . ayose in this section also [chie@y in relation to the United Kingdom pYoposal], and the 

view was expressed that this futor should be 

byought out separately in cross-tabulations in 

the same way as age OY sex. (re$ 48, p. 29) 

It was decided to circulate both documents to 

obtain comments on “whether alignment with 

the ILO classification of industrial accidents 

was desirable; the level of detail needed in the 

ICD; and the relative weight of transport accidents” 

(ref. 48, p. 30). 

17 
Accidents, Poisonings, and 

Violence (N Code) 

In late 1961 the WHO classification subcommittee recommended that the N code, on 

nature of injury, should be examined in relation 

to the E code, “with a view to developing closer 

correspondence between related categories, ” as 

for example by using the same numbers in the 

two codes for the same conditions, with differentiation between them by the letters (ref. 10, 

p, 26). It was also recommended that WHOcontinue 

to cooperate with ILO with respect to “a short 

classification by broad anatomical site and type 

of injury . . . to be used in statistics of industrial 

accidents, ” and it was suggested that the present 

N code “could be adjusted to suit the purpose” 

(ref. 10, p. 26). 

The WHO classification subcommittee in late 

1963 considered two complete revisions of the 

N code, once more from the United Kingdom and 

the United States. Like its E code, the United 

Kingdom’s N code was compatible with the ILO 

nature-of-injury classification. To accomplish 

this it set up “for the main types of injury, a 

two-digit code for site to be used in conjunction 

with a two-digit code for type of injury” (ref. 

48, p. 30). The U.S. National Committee submitted 

Chapter XVII, “Injuries and Adverse Effects 

of Chemical and Other External Causes, ” of the 

American adaptation of the ICD for indexing 

hospital records (ref. 33, vol. I). As the WHO 

subcommittee pointed out: 

Apart fvom the section on poisonings, which 

was ~adically alte~ed, this used the same threedigit categories as the ICD, omitting a few categories for “multiple injury, ” but utilizing the 

fourth digit for increased specijlcity of site or 

type of inju~y. (ref. 48, p. 30) 

The section on poisonings in the American 

diagnostic index indeed was different from the 

Seventh Revision. The index section for its 

categories 960-989, “Adverse Effects of Chemical 

Substances,” not only brought the list up to date, 

occasioning many new entries and many changes 

of position, but it also provided for continuous 

contemporaneousness: 

In orde~ to keep ab~east of new dregs this section is keyed to the continually ~euised Hospital Fo~mulaYy of the AmeYican Hospital FoYmulavy Service (AHFS) published undev the 

direction of the American Society of Hospital 

Pharmacists. In coding adve~se effects of drugs, 

first determine the list numbey from tke AHFS 

FoYmula~y. Then by tunaing to the numerical 

sequence ofAHFS list numbers which is located 

unde~ Effect, adverse, drug in the ICDA [Inte~­

national Classification of Diseases, Adapted] 

Index, the coyyect diagnosis code can be found. 

(ref. 33, vol. I, p. 240) 

On the second matter mentioned by the WHO 

subcommittee, in the Seventh Revision classification the fourth digit can be used throughout for 

10 rubrics, on nature of injury, ranging from “.0 

Simple (not characterized below)” through to “.8 

Open wound with infection and foreign body, with 

or without delaying healing” and”. 9 Late effects of 

injury. ” It is not known whether these digits have 

been much used, nor whether they have provided 

useful information. 

The WHO subcommittee requested that the 

United Kingdom and United States proposals be 

circulated for comment. 

Physical Impairments 

A group has been engaged since early 19S1 

in a study of how physical impairments should 

be classified, working on the following charge: 

To deteymine cuwentpractices in coding pkysical impairments and the type of classification 

needed foy statistical studies of data from kospitals, clinics, disability plans, andpublic health 

pyograms. (ref. 63, p. 12) 

A questionnaire was prepared and sent to all 

known American users of a code on physical 

impairments. It was also circulated by a subcommittee of the Canadian National Committee 

to Canadian users (ref. 81, p. 3; ref. 82). The 

Canadian group proposed only to establish requirements for a classification, which they did, 

without actually preparing a classification, Replies from American users suggested that a code 

was needed, but 

18 
so .fav did not yield a clear-cut indication of a 

definite type of classification . . . that would 

meet the needs of the Respondents. . . . The~e 

appeared to be sufficient indication of general 

intevest and co}tsistency in cevtain aveas to 

Warra)lt developing some concvete tentative 

proposals fo~ a fairly comprehensive scheme 

. . . to consist of a series of about th?’ee OYfmy 

rather simple codes with possible alternatives 

in cevtain aveas, [including] some that might 

k used independently and othen that would be 

more or less supplemental to some othey basic 

code. @cf. S3, p. 3) 

These activities were thus summarized in the 

following National Committee meeting: 

Tky aye worl~iug on seveyal difleyent codes; 

one to descyibe the impairment, anothey to give 

the etiology of the impairment, a thiyd which 

will indicate the extent of the impairment, and 

a fouvth to indicate the extent of Rehabilitation 

potential. @cf. S4, p. 3) 

At the rather early date of 1953, this technique 

promised to open up potentials of coding that 

might make use of the almost limitless combinatorial possibilities of electronic data proc­

~’ssing, while at the same time considerable 

benefits would still be available through use of 

less sophisticated processes. From time to time, 

cons iderably later, there has been discussion 

in WHO circles of a so-called “pyramidal type of 

classification” for the entire ICD which would 

have somewhat similar attributes, and at any 

rate should make it easy to derive short lists 

in a systematic manner from the full ICD list 

(rcf, 10, pp. 29-30; ref. 48, pp. 10-11; and 

refs. 85.87). To date little or nothing has been 

done in relation to the physical impairments 

c Msification to make it conform to the plan 

dcwcrihcd before. 

By May 1955 the experts had “prepared a 

draft of three integrated codes which describe 

(1) the nature and site of the impairment [three 

digits], (2) the etiology of the disease or injury 

[two digits] and (3) the extent of disability produced [one digit]” (ref. 14. Cf. ref. 88). An unnumbered document, reference 89, was ready by 

October 1955 (ref. 90, p. 1). The Association 

for the Aid of Crippled Children held a meeting 

in October 1955, from which a cooperative arrangement with the National Committee resulted. 

In September 1956 it was noted that 

?’ecent legislation under the Social Security pYogram involving pemons suffeying peymanent 

disabilities has made it necessayy foy that organization also to have a means of classifii~ 

impairments. The ChaiYman was Yequested to 

add to the Subcommittee on Physical Impairments two peysons qualified to YepYesent the 

needs of the Association foy [the Aid ofl CYippled ChildYen and the Social Secwity gYoup. 

(Yef. 91, p. 2) 

Already, however, a meeting with the Office 

of Vocational Rehabilitation and other interested 

groups had decided 

that the code being developed . . . would not suffice foy functional pwposes. . . . A vocational 

guidance staff membey is not only interested in 

how many limbs a client may have lost, but primayily in what he can do with what Yemains. 

(YeJ 92, p. 2) 

It was also agreed, however, concerning development of a functional code, that “if at all possible 

this work should be under the general ‘umbrella’ 

of . . . [the] subcommittee” (ref. 92, p. 3). The 

Association for the Aid of Crippled Children 

thereupon received a grant to develop a suitable 

functional code relating to rehabilitation potential. After editing and redrafting, nine field 

tests of the various codes that had been developed 

were started, beginning in 1959, under the auspices of the Steering Committee on Rehabilitation 

Codes of the Association for the Aid of Crippled 

Children (ref. 93, p. 2). Upon the conclusion of 

these tests and further editing, “Rehabilitation 

Codes—Five Year Progress Report, 1957-1962” 

was issued by the Association for additional 

field trials. To this work National Committee 

efforts had concretely contributed only the classi19 
fication of physical impairments and the etiology 

code. c 

In the Seventh Revision of the ICD, many 

impairments are classified either as late effects 

of a disease or injury, or as chronic diseases 

and conditions; but in addition 

Supplewzentavy Classi’cation 1’50- Y79 classifies impairments by cause with fourth digitsfov 

site and extent of involvement. Nos. Y80- Y88 

providefoy blindness and deay?zess with a fowth 

digit specifying etiology. While perhaps useful 

for geneval purposes, the ICD has b~en proved 

an inadequate basis for collecting detailed data 

as needed by agencies concened with physical 

impaiyrnents and their rehabilitation. (ref. 36, 

p, 5) 

In January 1961 the National Committee suggested that the rehabilitation codes be considered 

for submission to WHO (ref. 95, p. 2), and 

they have been so submitted. 

Operations and Treatments 

At the Seventh Revision Conference it had 

been recommended “that WHO take steps towards 

the eventual establishment of an international 

code of surgical operation” (ref. 37, Recommendation 3.6, p. 15). Accordingly, the National 

Committee in late 1963 submitted to WHO the 

“Classification of Operations and Treatments” 

which concludes the “International Classification 

cThe National Committee has “raised a number of questions concerning the Rehabilitation Codes. Among these were: 

(a) The relationship of the U.S. National Committee on Vital 

and Health Statistics to the Manual, as given in the text of 

the report . . . suggests a closer association with the 

whole manual than with the two parts with which it is concerned, (h) Many of the classifications are not designed for 

statistical purposes but for the administrative operation of 

programs, (c) The section on socioeconomic characteristics 

might very well be viewed from the standpoint of the Census 

classification in order to relate data to the population at 

risk, and (d) The identification of services code is not useful 

from the standpoint of medical rehabilitation. It was suggested that a test of reliability be included in the field tests 

on tbe applicability of the code” (ref. 94, p. 3). 

of Diseases, Adapted” (ref. 33, vol. I, pp. 279-

375). 

FERTILITY AND POPULATION 

STATISTICS 

The Committee has been responsible for 

four thorough studies of fertility and population 

questions in their relation to the Americ m 

situation. Of these studies three were conducted 

while Pascal K. Whelpton was Chairman of the 

Subcommittee on Fertility and Population St~­

tistics. Mr. Whelpton also served on the National Committee itself from its inception, w M 

its Vice Chairman from 1958, and its Chairm m 

in 1961. 

Needed Fertility Statistics 

Study of fertility and population questio IS 

began for the Committee when Whelpton a Id 

Dorn were asked, apparently on an ad hx 

basis ,d 

to act as a subcommittee to prepare a statement 

on what information is needed concemaingfevtility. The assignment includes the discussion of 

the stage of demographic knowledge in the Unr%?d 

States and of sozu-ce material needed to prouide 

fertility data, with recommendations for obtaiizing these data from census and from registr(~­

tion records. (ref. 97, P. 4) 

The requested report was ready by Octob w 

1950 (ref. 98) and accepted to be circulat :d 

to demographers for review and comment (ref. 

99, p. 2). The final report (refs. 100, 101) w~s 

essentially the same. 

dIn tbe Committee’s first annual report, for fiscal year 

1950, this was still listed as an ad hoc subcommittee, but its 

membership had been enlarged, perhaps because at the National Committee’s fourth meeting “the members request ~d 

additional assistance from the National Office of Vital Statistics and the Bureau of the Census” (ref. 96, p. 3). FrCm 

that time on the subcommittee included, besides WhelpUm 

and Dorn, only experts from the country’s vital statistics m]d 

population agencies. 

20

This study is a clarion “demand for new 

and greatly detailed forms of vital statistics 

and census data” (ref. 100, p. 196). In greater 

detail, the report found that 

move information is needed on ‘patteYns of chi.ldheaving’ i?~ the United States, with pavticulay 

vefevence to the changing size of family, the 

timingof childbea~ing, and the dynamics of family fovmation and dissolution. Much remains to 

be done in the study of social and psycholo~-cal 

factors a~ecting fertility and in the extent to 

which couples attempt and success$dly plan the 

nmnbev and spacing of their children. (ref. 101, 

p, 193) 

There is need, that is, to turn attention away 

from “short-run fluctuations in birth rates” to 

“the total number of children eventually born 

to the average couple . . . . [But] it is not sufficient to have answers to these questions for 

the Nation as a whole” (ref. 101, pp. 193-194). 

One also needs to measure fertility in groups 

that deviate above and below the national average. 

After summarizing in Part II the presently 

available fertility, population, marriage, and 

divorce statistics, in Part III the report considers “Recommendations for Federal Agencies’ 

Activity in Obtaining New Fertility Data and 

Improving Current Series,” and enumerates the 

following needs. (Items are grouped differently 

than in the document; ref. 101, pp. 200- 202.) 

A. IWtiolityStatistics: 

10 Additional tabulations of available data: 

a. Birth order by age of mother by race


(and by nativity of white mothers) for


W.rge cities and various population size


groups, and possibly for staadard metro­


politan statistical areas; b. Occupation


of father by such characteristicsas birth


order, age of father, and race.


2. Increased reliability of basic data. 

3,	 New data not available from the birth cer­


tificate: a. Interval between current and.


last previous birth; b. .Daration of mar­


riage or age of mother when married, with


distinction between first marriages and


remarriages; c. One or more measures of


saciaeconomic status.


4. Improvement in reporting fetal deaths.


B. Cencus and Survey Statistics: 

1.	 Additional tabulations: a. As yet untabu­


lated data from 1950 census; b. Study of


child spacing on a national scale and for


various groups; c. Use of Current Popu­


lation Survey (CPS) to measure changes in


fertility.


2. Measures to improve reliability.


c. Population Base Data: 

1.	 More population estimation to pe-rmitrate 

calculations on variables indicated above. 

2.	 Extension of CPStogive more detailed data


on population characteristicsbyage,color,


and r?gional detail.


D. Marriage and Divorce Statistics:


1. Increased and more uniform coverage. 

2. Additional data:a. Ages of bride and groom


by order of marriage; b. Interval between


divorce or death of spouse and remarriage,


number of previous marriages and how each


was terminated; c. Duration of marriage


prior to divorce by number of children by


age of woman.


Later Review of Needed Statistics 

In May 1954, a little over 2years after the 

above-described study had been published, the 

Committee asked its subcommittee 

toindicate the oydeyofpyioyity ofstudies Yecommendedinits yepoyt. . . withsuggestionsfoy 

actions needed to implement the recommendations; to outline the kinds ofpoPulation statistics needed foy health statistics; ana!toyepovt 

onthecrmrent stateofdevelopment oftechniques 

ofpopulation estimation, apYogYamfoY experimentation, and means fo~promoting activity in 

this ayea. (ref. 20, pp.2-3) 

A draft (ref. 102) was accepted by the Committee “withsome modifications, ” (ref. 90, p. 2). 

In May 1956 this report, only slightlyaltered, 

was published as “Progress in Development of 

Fertility Statistics and Population Estimates” 

(ref. 103). In the first part of the report, the 

several recommendations made previously were 

reviewed, progress was noted, and additional 

recommendations were made as required: 

A. Natality Statistics:


1.	 Additional tabulations of available data: 

Some additional tabulations were made for 

1949 and 1950, but with some cutback 

thereafter. 

21

New recommendations: 1.1 Essentially the same


commendation as A.1.a above; 1.2 Development


of a satisfactoryplace-of-residenceclassifi-


cation for canputing vital rates; 1.3 An adap­


tation of A.1.b above; 1.4 The Federal vital


statistics agency should take over preparation


of the fertility tables for birth cohorts of


women, then being prepared by the Scripps


Foundation for ResearchinPopulation Problems.


2.	 Increased reliabilityofbasic data:Studies


of 1950 birth-registration completeness


have been published; steps have been taken


to improve residence information.


New recommendation: 2.1 More attention to


Kte progrems; study of practicability of


1960 test of birth registration and infemt


enumeration completeness in areas seriously


deficient in 1950.


3. New data not available from the birth cer­


tificate:	 Little progress in getting the


information indicated as needed added to


the certification;some data on child spac­


ing sad socioeconomic characteristicsnow


available from Census; resistance to edu­


cation item on certificate on part of data


providers, and even data users.


New recommendation:3.1 Further efforts to get


~ormation on child spacing.


4, iinprovementin reporting fetal deaths:


New recommendation:4.1 Study of experience of


= 8 areas requiring registrationofall fetal


deaths.


B. Census and Survey Statistics:


1.	 Additional tabulations: some at first untabulated 1950 fertility data have been 

end will be published through private 

grants; CPS isbeing used.for new fertility 

data. 

New recommendations:7.1 Further publication of


= 1950 data; 7.2 Further use of CPS for fer­


tility data; 7.3 Speedy publication of now­


available child-spacingdata;7.4 Larger sample


for fertility questions in 1960 census.


2.	 Measures to improve reliability: some in­


formation has been published on infants


missing in the census for 1950,but not all


loopholes have been studied.


@ recommendation:8.1 Further improvement in


1960 census.


c.	 Population Base Data: not covered in this detailed way. 

D. Marriage and Divorce Statistics:


1.	 Increased and more uniform coverage standard records have been recommended;arraugements have been made for establishing marriage and divorce registration areas. 

2.	 Additional data: considerable additional


data are now available, but the coverage


is still very incomplete.


~ reconnnendation: 6.1 Continue efforts to


obtain the needed data from more areas.


The report found that adequate population data 

for health needs were available for the country 

as a whole and its subdivisions in census yeari:, 

and for the country as a whole in other yeart{, 

but that “the situation is quite different for all 

geographic subdivisions below the national lew:l 

in years between censuses . . . . The timirg 

as well as the content of population estimates 

is important from the standpoint of health need~” 

(ref. 103, p. 438). 

After a description of current methods of 

population estimation, whose brevity is mace 

possible by 18 explanatory references (ref, 10I, 

part II, pp. 439-440), the report, Part IV, developed “A Program for Experimentation cn 

Population Estimates.” As the analysis note::, 

the chief problem now interfering with satisfactory local-area population estimation is internal migration. The report concludes withtke 

following recomm”endation: 

The need for cuvrent annual population estimates for States, and for the cities and countits 

withlargerpopulations is uygentandcontinums 

inthefields ofpublichealth, demography, bws~­

ness, and community planni~. . . . Use oftle 

BOASIIBuveau ofOld-Ageand Suvvivovs Insu~’­

‘ante] and the Intevnal Revenue Bureau recon’s 

seemstohave greatpotentialities forimprovhg 

the estimates of internal migration. Itisrec ­

ommended that vigorous efforts be made . . . 

to obtain the financial suppovt required fo~a 

move adequate estimatesprogram, andpartic~­

larly for the migration aspects ofsuchaprcgram. (ref. 103, p.442) 

Recommended Census-Period Studies 

In June 1957 the Committee asked for a 

report on fertility studies centering around dala . 

available in the 1960 census period. The ori~:­

inal and amended changes are given in references 65 (p. 3) and 104 (p. 1), respectivel,~. 

Results of this investigation were published in 

June 1959 (ref. 105), after being accepted hy 

the Committee (ref. 106, p. 3). The report first 

outlined the kinds of data expected from the 

census and from birth records, and then suggested two kinds of studies—substantive and 

evaluative—as follows: 

22 
Substsmtive Studies


1, Monograph based mainly on census data.= 

2.	 Monograph utilizing birth-registration


statistics, bringing up to date Vital Sta­


tistics Rates in the United States, 1900-


1940,but also including “a thorough evalu-


ZEGn of the quality ‘ad usefulness of all


vital statistics available for all or part


of the 60-year period” (ref. 105, p. 152).


3,	 Concepts of family size: a study primarily


of the relationship betweenthe residential


family as defined by the Bureau of the


Census and the biological groupof children


ever born to the women in a household.


4. The effect on fertility of the dissolution


of marriages by divorce or death, and of


remarriage.


5. Interrelationshipbetween changes in eco­


nomic conditions and changes in fertility:


ona regional as well as anational basis;


using more refined measures as, for ex­


ample, age-parity-specific birth prob­


abilities;


inquiring into the extent to which pros­


perity and.depressionare associated with


inter-cohort differences in age of women


at childbearing.


6.	 An evaluation of 1955 expectations regard-


ing childbearing during 1955 to 1959.


7.	 Geographic variations in fertility includ­


ing, in addition to obvious subdivisions,


studies of fertility rates for:


minor civil divisions end by distance


from a central city;


vsrious parts of acentral city or metro­


politan area, by demographic and socio­


economic characteristics;


communities of different sizes or with


differing number of dwelling units per


structure;


levels of living.


8,	 Cohort fertility tables for regions or


States.


9. Birth spacing studies.


Evaluative Studies


1,	 Completeness and accuracy of birth regis­


tration, to include each of the 14 States


with less than 97 percent completeness in


‘The reportsuggestedthatthisbookmightincludedata 

fmm other sources,as forexamplevital statistics
 and cohortfertility studies.This agreesfairly
 wellwitha mono­


gmph beingpreparedin the APHA-sponsoredseries
which


1950> and also a sample of States where


registration completenesswas high.


2.	 Completeness of census enumeration and


accuracy of data.


3.	 Completeness of reporting on children ever


born (four methods are suggested).


4.	 Comparison of cumulative birt+ rates ac­


cording to the 1960 census, cuxrent popu­


lation surveys, smd cohort fertility


tables.


Fertility Measurements 

By mid-1962, a slow but steady decline in 

the country’s birth rate and its fertility rate 

had been continuing for 5years. Demographers, 

however, found it difficult to assess thesignificance of this trend with the measures currently 

available. Accordingly in May it was suggested 

that the problem be studied (ref. 94, p. 5), and 

in November it was decided that a statement 

should be drafted as a frame of reference for 

such a study by a new group of demographers 

(ref . 41, p. 3). This statement ran as follows: 

TheSubcommittee wasaskedifa change infevtilitywasdevelopirzg, andwhethevozw cwyently 

published measures are adequate to Yeflectit. 

Theproposed tasks were:-

1. To study the adequacy ofmeasuyes offeytility that aye curyently beingpublished, and 

to recommend needed improvements oYa.?­

tenuztiveseyies. . . andto recommend reseaych that may be needed inorderto develop such measures. Attention should also 

be giventomeasuyes offeytilitywhich would 

havesome value foypvo)ections into thej%­

trwe. 

2.	 TheSubcommittee shouldbe conceYnedpYimavily with measuyes that can be provided 

periodically. It should, howevey, take into 

accountinfoymation whichmight yesult from 

Yepeated sample sr.wveys anzi censuses, as 

wellastheinformation whichisderived from 

YepoYts ofbiYth Ye@”stYation. Data available 

foyonly asingle point in time, oyfov onlya 

limitedayea, should notbeignored,fo~ they 

of and analyzes andvitalstatistics may pyovide leads to useful measuyes draws tx+gether population 

dataoentcvingaroundthecensusperiod. feytility. . . . 

23

Items Pvoposed for Particular Attention 

1. Standardization of BiYth Rates. 

2. Cohovt FeYtility. 

3.	 Information needed for sho?+yange projections of fertility. 

4. Possible changes in the biyth certificate. 

5.	 Sample collection of data on planned completed feytility. 

6.	 Public information pyogvam on the importance of feyti.lity statistics. (7-ef. 107, unnumbered intyoductoyy pages) 

Through effective division of labor it was 

possible for the group to prepare a draft report 

for submission to the April 1964 meeting of the 

Committee (ref. 108). In considering this draft, 

vayious Committee memben commented upon 

lack of YefeYence to measurement of illegitimacy; possible use of some form of standardization of Yates foy changes in age-composition 

of mothey; because feytility peyfoymance in the 

$&ye depends on people not yet mayyied, need 

to queyy expectations of people not yet rnawied 

. . . consideration of possible measuyes of feYtility not cwryently published; and too much emphasis upon completed fertility and cohort Yathey 

than peyiod fertility, with need foy more attention topeyiod Yates as they Yelated to completed 

feytility. (Yef. 109, p. 2) 

A revision of the report was thereupon prepared 

(ref. 110). The report reaches the following 

conclusions (ref. 110, pp. 3-5): 

I.	 A change in fertility has been developing 

in the United States. 

TheYe is no doubt about the decline in~period 

);~;ility. . . . It can be said with a fair degyee 

of confidence that the vise in completed feytility 

that was initiated by the cohoyt of about 1910 is 

likely to continue only th?’ough the coho~ts bomz 

in the early 1930’s . . . and eayly 1940 ‘s. . . . 

II.	 Cun-ently published measuyes aye adequate 

to YefLect ceytain changes in feytility but 

requiye improvement and Refinement. 

. . . A deficiency in these data . . . is the lack 

of information on the mayital cha~acteyistics 

of the population. Data such as age at marriage 

and duyation of rnawiage foy the parents and 

foy the total childbeayingpopulationin each year 

aye necessayy. . . . In addition, information on 

the spacirg of child~en in relation to date @ 

rnawiage and date of biyth of the pyevious child 

would peymit an evaluation of the effects of 

changes in the timin.of biyths. . . . Information 

on socioeconomic status of payents would also 

be usefil. 

. . . SeYious thought mi~ht be given to adding a 

measuye called the “Standardized” or “Ageadjusted GeneYal FeYtility Rate. ” . . . It is Yec ­

ommended that two seyies of cohoyt feytiliiy 

Yates be maintained, i.e., one foy biyth cohovts 

and one for mawiage cohoyts. 

Also recommended were uses of followback studi~s 

and the National Health Survey to obtain information on number of children ever born and th~ 

date of first marriage of married women. Th~ 

live-birth certificate should be used as a sampling frame to get additional fertility information. 

III.	 MoYe YeseaYch is YequiYed in the ayea bf 

FeYtility Projections. 

. . . ThYough the CuYrent Population Su?wey th ? 

Census Bweau should collect peyiodic data o% 

expectations yegaydi~ ultimate size of famil.v 

and expectations of biyths duying the next fiv ? 

yea?%. Research m“models foy population projections is wholeheartedly endonsed. The Divi ­

sion of Vital Statistics should itself enter th ? 

field of making feytility projections. 

The Subcommittee also recommends that th Y 

woyk ofpyivate institutions be sustained and enlayged. (Yef. 110, p. 5) 

IV.	 FuYtheY YeseaYch is requived in ayea~ 

wheye data aye absent OY scayce. 

. . . It is Recommended thatfoundations, universities and other pyivate institutions . . . [col ­

lect and study] data onfamily planning pyactices 

and attitudes, fecundity and fecundity impairments, and Yeligion of payents. Because of th e 

persistence of high feytility among nonwhites 

and Catholics in the United States, studies especially designed foy these groups should be 

encouraged. 

24 
V.	 Information on fevtility developments 

should be communicated to the public. 

. . . The Bz.m-eauof the Census and the National 

Center foYHealth Statistics aye uyged to devote 

a portion of their pvog’ram to those jwblications 

wkich will inform the lay public concenai~ thei~ 

work. 

It is vecomrnended that the National Division 

of Vital Statistics write an annual evaluation of 

cuvrent fertility tvends that would hying togethey 

all of the latest information on cohovt fen%lity, 

tinting, and expected childbearing fvom a vaYiety of sources. . . , This veview of current 

t~ends should be wvitten in non-technical language and be made available to the news media. 

(Yef. 110, p. 6) 

This report draws the conclusion that 

all attempts to make the feytility pyocess moye 

specific [statistically] . . . aye inherently incapable of p~ovidingreliable predictions about the 

subsequent fevtility of cohoyts of women who 

are cumently in the childbearing ages. . . . 

(Yef. 110, p. 9) 

Though the surveys of expected completed family size that have been conducted since 1955 have 

thrown much light on fertility questions, “their 

usefuhiess is somewhat limited since the survey 

cannot cover women not yet of childbearing age, 

and in a very few years it will be they who will 

be bearing most of the children” (ref. 110, p. 26). 

In summary, two things may be said, of which 

the first is that 

no project for making bivth projections now 

takes account of all the variables which have 

been shown to have a bearing on the level of 

fertility and foy which data aye available. It 

would be desiyable to devise a method which 

wowld take account of all important vaviables if 

only to pyevent incongruities that may be implicit in assumptions. A jidly articulated methodology would account for at least the following 

va~iables: completed fentility, age of mothev, 

marital status, parity of mother, and bivth interval. The cohort fertility projections of the 

Growth of AmeYican Families Study take account only of completed fei+ility, age, and maYi ­

tal status. The mawiage-pan”ty pyogyession 

method does take account of payity and inteyval 

as well as mayital statws but at pyesent disYe ­

gayds completed fertility and has only indirect 

control on age. The sheey magnitude of the com­

@tations has been a hindvance to complex models in the past, but the availability of computers 

and of the condensed languages foy programming 

should now make them practicable. (Yef. 110, 

p. 27) 

The other final consideration looks perhaps 

at the same complex of factors, but views them 

from the standpoint of social patterns which are 

stable even while the y change: 

It is tme that completed feytility changes, but 

it does not change vapidly and does not behave 

erratically. . . . FeYtility values aye embedded 

in a cwltuyal context which changes slowly, and 

these values aye the most impoytant determinant of the rzumbey of childyen expected and the 

numbey actually bonz. (Yef. 110, p. 32) 

Is there any way of quantifying these slowly 

changing social processes as they embody themselves over time in different patterns of family 

formation? 

Two Briefer Studies 

More Detailed Birth Statistics on a Current 

Basis 

In June 1958 the National Office of Vital 

Statistics asked the Committee for “advice on 

data that should be obtained currently on fertility statistics’ r (ref. 111, p. 4). The result was 

two relatively brief documents, “Providing Birth 

Statistics on a Current Basis” (ref. 112) and “A 

Current Birth Sample Program” (ref. 113). Recommended was as ystematic 5-percent probability 

sample of live births, to be tabulated quarterly on 

the following variables: 

Age of mother by 5-year age groups 

Order of birth of child (each order from 

1 to 7, with 8th and higher orders combined) 

Place of birth, or place of residence of 

mother, by four regions (Northeast, North 

Central, South, West) 

Color of child (white or nonwhite) 

25 
It was recognized that it “is not likely . . . that 

the sampling error will be small for all of these 

categories. ” It was recommended, however, “that 

the data be tabulated and published in this detail 

so that users can make the combinations which 

are of most value to them. ” With births running 

at say 4 million per year, the probability would 

be about 95 out of 100 that the estimated number 

of second births to women 20-24 years of age, 

for example, would not differ from the true 

number by more than 2.6 percent. 

This proposal has not as yet produced a 

practical result. 

Need for Quinquennial Census 

In January 1960 the Committee asked for a 

statement on the need for a quinquennial census 

(ref. 114, p. 4). The resulting report after being 

accepted (ref. 93, p. 3) was forwarded to the 

Surgeon General. It surveyed current programs 

related to the proposal, of which there were by 

then a large number (ref. 115). Costs were discussed, thus a sample survey covering 3 percent 

of the population “could provide much analytically 

useful data for States, urban and rural, and for 

large metropolitan areas, at a cost of about $7 

million” (ref. 115, p. 5), while a quinquennial 

census might cost $50 million. In concluding the 

analysis, “the subcommittee recommends the 

endorsement of the principle of a mid-decade 

census, supplemented by sample surveys, with 

no curtailment of the decennial census program” 

(ref. 115, p. 8). 

In May 1962 the Committee was informed 

that, at hearings on the proposal of a quinquennial 

census, the Bureau of the Budget had expressed 

interest in sample surveys for getting current 

population estimates, rather than such a census 

(ref. 94, p. 5). 

MEDICOLEGAL DEATH STATISTICS 

Improving hfedicolegal Certification 

It is estimated that from 20 to 30 percent 

of all deaths occurring in the United States are 

medicolegal deaths— deaths, that is, which fall 

under the jurisdiction of a coroner or medics’ 

examiner, as the law may direct. These 300,00[1 

to 450,000 deaths differ in kind from State tcl 

State: 

The cases that clearly come under the medicolegal jurisdiction aye deaths resulting from violence (that is, accident, suicide, or homicide) 

and deaths in which there is reason to suspec~ 

violence. . . . In some areas, all deaths wiihout medical attendance are investigated by tke 

mediocolegal authoyity, while other areas vefe~’ 

such cases to the local health officer. In some 

areas, the medicolegal ofiicev may investigak 

deaths resulting from known or suspected industrial diseases, deaths where the cause o; 

death cannot be determined, deaths wheye tht 

identity of the deceased is not established, etc. 

There ave jurisdictions where the medicolega, 

ojj%cet’ investigates any death occuming in c 

hospital within 24 hews after admission. 

. . . . . 

The function of the medicolegal officey is tc 

cuwy out official, impaytial investigation OJ” 

deaths within’ his statutoyy jurisdiction, including a determination of the cause and mode oj” 

death. (ref. 116, pp. l-.Zj 

Although medicolegal deaths are important 

because of their numbers and concentration amen;; 

certain causes of death, it was felt that man f 

medicolegal authorities were unaware of the 

nonlegal ramifications of medical certification. 

In October 1955 (ref. 90, p. 3), therefore, th: 

Committee decided 

to study the problems of medical certification 

of causes of death coming within the purview qQ 

the medical examiner and the coroner; to delineate the various problems from the statistical as well as the medicolegal viewpoints; ant 

to foymulate plans foy cyeating a bette~ understanding of medical certification pyocedure 

(ref. 63, p. 16) 

A draft report was prepared and sent to the 

registration executives of the 56 autonomous 

vital registration areas of the United States and 

26 
to 50 selected coroners and medical examiners. f 

After several revisions, the report was accepted (ref. 122, p. 2) by the Committee and 

published (ref. 116). In June 1961 the Committee 

was informed that the report had been endorsed 

by the American College of Pathologists and the 

National Association of Coroners (ref. 123, p. 4). 

Five areas bearing on medicolegal certification are considered in this document: 

Registration laws related to medicolegal 

certification 

Kinds of deaths requiring medicolegal investigation 

The death certificate and medicolegal reports 

Needed statistical classification 

Information programs for medicolegal 

officers 

Registration Laws Related to Medicolegal 

Certification 

After defining “physician” and “’physician in 

attendance upon the deceased, ” it is recommended 

that the physician be authorized to certify the 

cause of death only if he views the body after 

death. For all other deaths, the case should be 

reported to the medicolegal authority, who may 

or may not decide to take jurisdiction. 

Since vital statistics acts and medicolegal 

acts differ widely in some States, it is recommended that they be revised so that they complement each other. Also 

wheve a death is subject to investigation, the 

law should vequive prompt notification to the 

medic olegal officer by eveyy person having 

knowledge of the case . . . . The coroner o?’ 

medical examiner should then make an immediate p~eliminayy investigation to determine 

wketkev ov not fwthev investigation is neces ­

sayy. If not, he skould immediately twn the case 

hack to the physician. (ref. 116, p. 9) 

f

First draft of report is given in reference 117; comments 

on this draft we in reference 118. The second draft is refw~~nce 119. Comments from registration officials and medicoIegal officers we summarized in reference 120 and given verbatim in reference 121. 

Since the local registrar of vital statistics 

is the only public official who is in a position to 

determine whether a competent person viewed 

the body and prepared the medical certification, 

A peymit should be Yequired to authoyize the 

disposal of a dead body OY its Yemoval J70m the 

State. Such a peymit should be issued by the local 

Ye@.stvay of the distyict in which the death occzwred OYwheye /the body was found, and then 

only when a satisfactorily completed death certificate is pyesented. If it is not possible to obtain a determination of the cause of death within 

24 hours of the death, the physician, co?zmer, 

OY medical examiney should be Ye@iYed to infoym the local Yegistyay whether there is a legal 

or medical reason why the permit should not be 

issued. (ref. 116, p. 11) 

To make this recommendation effective, a study 

of problems relating to it in various areas of the 

country should be made and guidance handbooks 

prepared. 

A 3-day filing requirement for death certificates was recommended, with special provision 

for sparsely settled areas and for cases, such 

as inquests, where more time is needed to secure completed certificates. Where the cause 

of death cannot be determined within the statutory 

time limit, the medicolegal authority should file 

a certificate indicating that the case is pending 

(ref. 116, pp. 12- 14). Amendments and corrections 

to the death certificate should be made by identical.. 

procedures. 

Kinds of Death Requiring Medicolegal Investigation 

The following kinds of deaths (ref. 116, pp. 

15- 16) should be investigated by medicolegal 

authorities to determine whether they should 

assume jurisdiction: 

Deaths due to violence, whether apparently 

homicidal, suicidal, or accidentally inflicted; 

Deaths occurring under suspicious or unusual circumstances; 

Deaths due to industrial diseases and injuries; 

27 
Sudden and unexpected natural deaths: “All 

deaths occurring unexpectedly where the 

deceased was notunder medical treatment 

for the disease orcondition believed to be 

the cause of death”; 

Deaths without medical attendance within 10 

days prior to death; 

Deaths occurring while in custody of the law; 

Deaths associated with diagnostic, therapeutic, and anesthetic procedures; 

Maternal deaths associated with abortion or 

suspicion of abortion; 

Deaths from diseases thought to be of a 

contagious nature. 

The Death Certificate and Medicolegal Reports 

(ref. 116, pp. 16-19) 

Until it has been established that every 

certifier must view the body before pronouncement of death, the medical certification should 

indicate whether or not the certifier did view the 

body. Since the facts certified must be different 

for medicolegal authorities and for physicians, 

death certificates should include a separate medical certification statement. Further, a study of 

forms used by coroners and medical examiners 

should be made to see how effective they are in 

securing information for needs served by death 

certificates. 

Needed Statistical Classifications 

(ref. 116, pp. 19-21) 

Medicolegal authorities need the rubric ‘‘undetermined” for certain violent deaths where, 

after investigation, “the circumstances of a death 

cannot be established. ” Prior to the Seventh 

Revision of the ICD, on January 1, 1958, violent 

deaths of undetermined circumstances were coded 

to accidents; thereafter, self-inflicted injuries 

not specified as due to accident or suicide have 

been coded as suicide, as have deaths where 

homicide and suicide are jointly named. However, 

the report recommends, “when the certifier indicates that the circumstance was ‘undetermined,’ 

the case should be tallied as such. ” 

Vital statistics tabulations have traditionally 

assigned deaths due to therapeutic misadventure 

to the disease for which the procedure was initiated. The report recommends that 

Multiple cause tabulations should show association between diseases (OYconditions) and misadventure during therapy, anesthetic, and diagnostic pyoceduyes. Where only one cause of 

death is coded, a special one-di~”t code should 

be added Youtinely to indicate deaths that result 

fyom misadventzme during therapy, anesthetic, 

and diagnostic procedures. (ref. 116, p. 21) 

Information Programs for Medicolegal Officers 

Medical examiners and coroners need guidelines to assist them in preparing medical certifications. The national vital statistics agent y “in 

cooperation with medical examiners and coroners 

should prepare suitable instructional material 

and initiate an information program” (ref. 116, 

p. 24). 

Improving Medicolegal Death Statistics 

In May 1963 the Committee decided to form 

a subcommittee to study statistics available from 

medicolegal deaths because of 

an exp?’essed desiye on the part of a few medical examinem to develop a system of gatheying 

and tabulating their basic data in a uniform fashion. Their puyposes were: 

1.	 To consolidate information fyom unifovm 

data 

2. To peymit compa~isons 

3. To stimulate reseaych among tht?nmelues 

4.	 To exchange information (and possibly, 

specimens) on YaYe events. (Yef. 124, p. 1; 

and Ye$ 80, p. 3) 

The final report (ref. 125) of the group was 

presented to the National Committee in April 

1964, by which time enough collaborators had 

expressed an interest in participating to make 

28 
approximately 60,000 cases available annually. g 

The basic recommendation of the report is 

as follows: 

It is recommended that a central o~ganization 

(Cented including representatives of selected 

medicolegal systems be established with the 

following functions and responsibilities: 

A.	 Develop a record system fov the collection 

of a core of basic information on investigated medicolegal cases; be Responsible for 

the processing, tabulation, analysis and dissemination of summarized data; ana!provide 

technical assistance and consultation to 

members of the gvoup and to outside investigato~s; 

B. Within theiy own organization, aryange fov 

special purpose reseavch projects; 

c. Promote the utilization of the core of basic 

information and stimulate ad hoc research 

studies by outside gYoups, and entey into 

contracts with such groups; 

D,	 Establish policy and administrative pYoce ­

duyes governing the quality of data, access 

to infovrnation, and costs of providing information. (vef. 125, p. 2) 

What this recommendation proposes is the setting 

up of a system of voluntary collaboration of several medicolegal jurisdictions, with certain standards for inclusion of areas, plus a mechanism for 

handling the data that the system would make 

available, which were thus described: 

The basic data which are common to all cases 

. . . are the items necessary for the completion 

of death certificates, a YepoYt from a law enforcement agency, photographs, and physicians’ 

examinations. For a layge poytion, when the circumstances wawant, specialized .?aboratoYy examinations and investigations of ci~cumstances 

‘Quotations in this section are from this report. The 

60,000 deaths available annually would include 40,000 unattended and unexplained deathe, sudden deaths when the decedent had apparently been in good health, and deaths in 

public places; 1,800 homicides, 3,700 suicides, 4,200 home 

accident fatalities, 6,000 vehicular accident fatalities, 1,200 

industrial acoident fatalities, and 3,7oo deaths due to other 

typos of accidents. 

suwoundingdeath are performed. Among these 

aye autopsy findings (gYoss and microscopic), 

chemical and immunological examinations, 

x-ray and anth~opometyic and anatomic measurements. (ref. 125, p. 3) 

Appendix B of this reference describes these 

data in more detail. 

The report lists 14 examples out of the 

man y medical, methodological, and epidemiological investigations that could be conducted 

either from data currently being obtained, or 

obtainable through research efforts. 

When this report was presented, 

the Committee went on YecoYd as endoning the 

idea of the centyal organization and ~ecom -

mended that a small group of potential collaborators exployefiythey the feasibility of cooperative effoyt, and pyomote a pilot study. The need 

for adequate statistical and pathological suppoyt was emphasized. . . . 

. . . . . 

The Committee appyoved a motion to uyge the 

National CenteY foy Health Statistics to pyovide 

suppoyt by Recognition of values to be deyived 

from this activity; to give consultative assistance to this development; and to endorse and encouyage effoyts of thisgyoup to seek fiscal support for development of a pilot program in this 

area. (ref. 109, p, 3) 

QUANTIFICATION OF WELLNESS 

Few can resist being intrigued by the preamble of the Constitution of the World Health 

Organization, with its bold declaration of nine 

“principles ,“ each centering around health, that 

are stated to be “basic to the happiness, harmonious relations and security of all peoples. ” 

And of these principles the first is certainly the 

most quoted and no doubt the most puzzling: 

“Health is a state of complete physical, mental 

and social well-being and not merely the absence 

of disease or infirmity. ” 

Can health in the World Health Organization 

or some related sense be measured, scaled, 

counted? In December 1957 

29 
Dr. [Halbt?rt L,] Dunn [Chief, National Office of 

Vital Statistics] presented the pvoblem of developing measwes of positive health, rather 

than of illness, for the consideration of the Committee. Several velated studies weve repoYted— 

the Pecki~ham Health CenteY experiment, the 

Army system of categorizing persons by means 

of a health pyofile, the University of Chicago 

stwdy of nonchmn.olo~”cal cvitevia of aging. It 

was also pointed out that health should be measured in terms of an individual’s functions. (ref. 

104, pp. 3-4) 

At this meeting an ad hoc subcommittee was 

authorized “to look into the possibility of measuring degrees of health. ” When this group reported, 

A subcommittee was authorized to explore ways 

and means of obtaini~ measures of positive 

health. beginning with an examination of the matevials available in the National Health Smwey 

and in the inuentoq that will be made . . . of 

agencies and individuals that might cooperate 

in Researches on positive health. (Yef. 111, p. 3) 

In its first meetings the subcommittee developed two apparently opposed ways of regarding 

‘‘wellness” (as yet undefined). One possibility 

was that wellness consists in realizing potentialities that are fundamental y human—’ ‘the living thing fulfilling itself” (ref. 126, p. 2). For 

example, it was stated that man is simultaneously 

physical, living, animal, and a reasoning being; 

and as the last he is a knower, a maker, and a 

lover, which are ways of fulfillment for man. 

One way of stating the second possibility 

was in terms of a probability definition: 

A general state of health [wellness ?] is a state 

of a @“ven man such that: 

(1) The behaviov of the man himself, and each 

of his components, is in one of its more 

pvobable conjigurationsfoy that point in the 

ideal life cycle. 

(2) The behavior of the man, the man himself, 

and each organization in the hievavchy of 

which he consists, is in one of the configurations more appropriate to the state of 

the highev organizations of which it is a 

part. I 

(3) The behavior of the man, and of each component of the man, is such as to maintain 

the inteqity of the highev o~ganization of 

which it is a pavt. (Yef. 127, p. 2) 

The essential difference between the tw j 

views is the difference between realizing potentialities and functioning according to more prob.. 

able configurations. The first view places morl ? 

emphasis on goal or purpose; the second on th: 

fact that choice actually is limited by the natural 

and social surroundings. When the first viet~ 

is at its worst it refers conduct to a merely abstract idea~ when the second view is at its worst 

it justifies accommodating one’s life to a mer{: 

“ecological niche. ” 

Among hypotheses that were entertained at 

this stage of the group’s thinking were th(: 

following: 

1.	 The level of wellness is reji!ected by the extent to which an individual realizes his full 

potential foy valued achievement. 

2.	 The degvee of health of an individual is vejlected by the soundness and functional efficiency of the mind and body together wit,~ 

its organs and parts. . . . 

3.	 Although health is Yelevant to wellness, wellness is not a function of health and is not 

necessarily positively cowelated with healtk. 

4.	 Physical fitness in the sense of high performance on muscle strength and coordina. 

tion tests and velated measuves is not synonymous with health. (Yef. 128, p. 1) 

The group then planned to take up, in turn, 

physical health, emotional health, achievement 

or fulfillment, and possibly creativity. Of thi~ 

program, only the first two phases were carriec 

out in any detail when it seemed best to cast UI 

accounts, which was done in a final report 

(ref. 129) and accepted by the Committee (ref. 

95, p. 3). 

This report reiterated the above-cited distinction between health and wellness, and stated 

the conclusion that “although health and wellness 

should not be considered to be synonymous they 

are, however, closely and probably indissolubly 

related” (ref. 129, p. 4) and not invariably with 

30 
positive correlation. “The relationship is not 

easily defined or described” (ref. 129, p. 5). The 

report proceeded to suggest two lines of research 

as offering the possibility of yielding quantitative 

data on health and wellness and their relationships : 

1. Longitudinal (cohort) studies based on 

“definite populations with relation tocbaracteristics appearing over time” in differential patterns (ref. 129, p. 7). These 

studies could be extended to past data 

if ways were developed of translating 

cross-sectional data into acceptable longitudinal data. 

2.	 Study of populations or groups of individuals thought to be representative of the 

categories to be studied —high and low 

levels of health and of wellness—and, as 

a fifth group a suitable stratified sample 

of controls, with these populations compared on: 

Pertinent medical history variables


Present physical state as determined by


medical examination


Present fitness, strength and endurance


Psychological background variables


Present personality structure (ref. 129, pp.


9- 10) 

HEALTH ECONOMICS 

In January 1961 the Committee decided to 

study the needs for statistical data in health 

economics, and shortIy thereafter set up a subcommittee with the following charge: 

To make a study and prepare recommendations 

as to aveas velating to the economics of health 

whe~e data are not now available or are not adequate for national planning in the health field. 

(ref. 130, p. 19) 

The group early decided to frame its report 

in terms of types of medical services and’ ‘major 

categories of services. ” The types of services 

chosen were the following: 

Physician’s services 

General and special short-term hospital services 

Long-term institutional services 

Drugs and appliances 

Dental services 

Miscellaneous other services for noninstitutionalized patients (ref. 131, p. 3) 

The “major categories of services” which were 

to be applied in turn to each of the services were: 

Resources


Use


Price


costs


Quality (ref. 132, p. 4)


In actually preparing the report some of the 

service categories were subdivided and, with 

respect to sources of funds, it was decided “to 

narrow the lens to medical services themselves 

and not include many peripheral areas, such as 

medical education and training of paramedical 

personnel, and traditional public health activities 

(environmental health)” (ref. 131, p. 2). 

Each subsection of the report considers in 

turn what statistics are needed, which of these 

statistics are presently available, and recommendations for action, which are divided into 

ongoing series and special studies. After a 

draft of the report had been prepared, it was 

sent to interested agencies. These agencies also 

were asked for data-collection forms, to be included as an appendix to the report. On the basis 

of comments that were received, a final draft 

was prepared and published (ref. 133). 

31

Ill. STRUCTURE AND BASIC WORKING ARRANGEMENTS


The term “National Committee” can be used 

to indicate either the parent Committee or the 

entire organization composed of that Committee 

and its subcommittees. The central Committee 

itself, its subcommittees, and relationships between these two groups will be briefly discussed 

in this chapter. 

STRUCTURE OF THE 

NATIONAL COMMITTEE 

The National Committee—meaning here the 

parent body—differs 

that, formally at any 

members nor chooses 

members [including 

pointed by, and will 

from 

rate, 

its 

its 

serve 

many committees in 

it neither coopts its 

officers. “Committee 

officers] will be apat the pleasure of the 

Surgeon General of the Public Health Service” 

(ref. 7, p. 12). In practice, the Surgeon General 

has acted on nominations made by the Chairman, 

with considerable actual responsibility resting 

in the hands of the Secretary. 

Membership of the Committee 

The normal level of membership of the Committee is 12, including its officers, and in fact 

no meeting has been held in which the number 

of members eligible to attend was less than 11 

or more than 13. 

Prior to July 1958 members served for an 

indefinite term. Minutes of the December 1957 

meeting of the Committee, however, contain 

the following item: 

It has been proposed that a system of Yotating 

membership be established for the National 

Committee in orde~ to provide an oppo~tunity 

for b~oader representation of p~oblem areas 

in health statistics. A term of office of four 

yearn was a.gveed upon; the first Yotation will 

be made on July 1, 1958. (re$ 104, p, 2) 

The Secretary has remained in office throughout 

the life of the Committee, to maintain continuity 

in Committee functioning and in providing secretariat services. 

Officers of the Committee 

The Committee originally had three officers, 

the Chairman, the Vice-Chairman, and the Secretary; but the vice-chairmanship has not bee~ 

filled in recent years. The Secretary is ex 

officio member of the Committee. 

Neither the Chairman nor the Secretary ar~ 

figureheads. While it is stated, for example, that 

“the Committee, through its chairman, will have 

the power to create subcommittees” (ref. 7, p. 12), 

the appointments have prevailingly been made 

by the Chairman, acting largely in terms of tht 

detailed advice of the Secretary. 

The Committee has had five Chairmen: 

Chairmau ESEx Date 

Dr. Lowell J. 1-17 February 2, 1949-

Reed September 28,1956 

Dr. Philip M. 19-25+ June 14, L957-

Hauser June 8, 1~60 

Mr. Pascal K. 2G-27 January 9, 1961-

Whelpton June 19, 1961 

Dr. Brian 28-31 October 30, 1961-

MacMahon May L7, 1963 

Dr. Robert 32- October 14, 1963-

Dyar 

#The Committee had no formally appointed Chairmax


for its 18th meeting, held February 1, 1957.


All Chairmen (except of course the first J 

had previously served as Committee members, 

The second Chairman had been a member fron L 

the Committee’s second meeting; the third frori L 

its first meeting. Both left the Committee by 

virtue of the 4-year rotation rule, which wa:; 

applied in staggered fashion on its initiation. 

The 4-year tenure of Committee member.. 

ship acts to decrease the term of office of th{: 

Chairman. Thus the present incumbent will bl: 

leaving the Committee, presumably after havin~~ 

served first as a member and then as Chairman 

for four meetings each. This also was true fo -

the previous incumbent. 

The general advantages — of a limited tenurt:

on the Committee appear to be obvious, but 

consideration should be given to: 

‘ 

32 
the merits of a 4-year limitation as opposed, 

say, to one of 5 or possibly 6 years; 

the desirability of extending the tenure in the 

case of Chairmen to say 3 or possibly 4 

years in that office. 

The Secretary oversees practically all of the 

administrative details involved in maintaining 

not only the National Committee itself, but the 

10 or so subcommittees that were currently in 

existence over recent years; he attends many 

subcommittee meetings and is entitled to attend 

all; he canvasses the field of public health to 

identify appropriate subjects for study and appropriate persons for appointment to the Nat ional Committee and its subcommittees; he 

maintains liaison with national and international 

public health organizations, including an especially active relationship with WHO groups which 

frequently requires him to attend meetings abroad; 

and he is called on for advice from many quarters 

because of the experience and associations that 

have accrued over the years. 

STRUCTURE AND ACTIVITIES 

OF SUBCOMMITTEES 

Membership and Officers 

The following passage describes the Committee’s subcommittees and states the conditions 

under which they are formed, function, and are 

disbanded: 

For study of particular problems, subcommittees shall be appointed by the Committee. These 

working pavties will be gene~ally small in size 

and com~osed of qualified technicians. The 

members of the subcommittees shall be appointed by the chaiyman of the Committee in 

consultation witk the chaivman of the respective 

subcommittees. MembeYs of the subcommittees 

wilt usually not be members of the Committee. 

The subcommittees shall serve until the completion of tkeir assignment, OYuntil discharged 

or reconstituted by the Committee. (Yef. 7, p. 12) 

Although the quoted statement is part of a formal document, it outlines two procedures for 

appointing a subcommittee that might differ 

under certain conditions. This was clarified 

when it was decided in March 1953 that it is 

“the responsibility of the Chairman to appoint 

all subcommittee members” (ref. 134, p. 1). 

In general, members of subcommittees have 

not been members of the parent Committee, although a few exceptions (chiefly subcommittee 

chairmen) might be cited. There is of course one 

general exception: 

In order that the secvetayy may be geneyally 

conversantwith all wo~k being conducted by the 

subcommittees, the secyetayy shall be an exofficio member of eveyy subcommittee fovmed, 

and as such shall veceive copies of all coYve ­

spondence OYother material which normally go 

to a membey of a subcommittee. (Yef. 7, p. 13) 

As with members of the parent Committee, 

subcommittee members are chosen because of 

their personal competence, not as official representatives of organizations. 

The policy statement was that subcommittees shall be small. The printed annual reports for fiscal years 1956-63 contain data on 

19 regular subcommittees out of the 25 that have 

functioned since 1949. (Figures exclude some 16 

or more ad hoc subcommittees. ) These data 

show that the typical size of a regular subcommittee has been seven members—an average 

that has been fairly consistently maintained over 

these years. 

Types of Subcommittees 

The National Committee has administered 

the technical studies of over two dozen groups, 

of which about a score have had a tenure of at 

least 2 years, over a period of 15 years. The 

subcommittees whose work was described earlier 

might not qualify as subcommittees in the dictionary sense because their membership for 

the most part is not drawn from the parent 

Committee itself. They are neither identical 

in form among themselves, nor do they constitute the only kind of subcommittee structure 

used by the National Committee. It will be convenient to distinguish at least the following kinds 

of subcommittee: 

33 
Ad hoc subcommittees (to use the name employed in Committee circles) 

“Definite charge” or “regular” subcommittees 

Synthesizing subcommittees 

“Control” subcommittees 

Ad Hoc Subcommittees 

There have been at least 16 ad hoc subcommittees: 

1949:	 medical care statistics 

case registers 

morbidity statistics (2) 

fertility and population statistics (became a regular subcommittee) 

1951: ICD Seventh Revision date 

1952: validation of surveys 

review of case-register findings 

review of morbidity survey report 

1953: 5-year review of National Committee 

1956: synthesis of vital statistics needs and 

marriage statistics reports 

1957: family classification for health purposes 

positive health 

1960: accuracy of vital statistics 

1963: needs and uses of hospital statistics 

preparation for 15th anniversary of 

National Committee 

Drawn largely from the ranks of the National 

Committee itself, and usually limited to three 

or four members, these groups have edited or 

reviewed subcommittee reports, attempted to 

present a synthesis or line of approach to a 

broad area, worked on a limited substantive 

task, looked into the desirability of establishing 

a regular subcommittee, etc. 

This kind of subcommittee may also be used 

to prepare charges to guide new subcommittees; 

explore relationships between existing subcommittees; consider possible contacts with other 

organizations; outline limited areas of Committee 

concern or estimate the merits of alternative 

techniques in some definite situation; clarify 

chosen alternatives. 

“Definite Charge” or “Regular” Subcommitte(xs 

These are the typical study groups working 

on more or less clearly assigned problems ~f 

which one naturally thinks when considering the 

work of the Committee. These subcommitte(!s 

are trying to find a solution for a particuli m 

technical problem or are carrying out some a::­

signed technical task. The Committee’s polit:y 

statement reads “within the scope of their a::­

signment, the subcommittees shall be free co 

function according to their best judgment” (rc f. 

7, p. 12). This statement has two closely relatt!d 

aspects—first an assignment, and thereaft~~r 

freedom to use judgment. The assignment [s 

usually neither more nor less explicit than is 

appropriate to validate the freedom. 

Synthesizing Subcommittees 

There have been several long-continuing 

subcommittees of this kind: Military Heal :h 

Statistics, Fertility and Population Statist ics, 

Classification of Physical Impairments, and pe].­

haps Hospital Statistics. on the one side, synthl:­

sizing subcommittees have had a series of pro]]­

lems in their areas referred to them by tl[e 

parent Committee, and on the other, they ha~’e 

exercised somewhat more freedom than is usu 11 

for subcommittees in determining the functiolls 

they perform. The Hospital Statistics Subcon 1-

mittee first produced a report on relating ho::. 

pital morbidity to morbidity in the communit ~, 

and thereafter developed a diagnostic index fiw 

hospital use. In connection with the latter a:;­

signment, it was necessary that contacts with 

a number of organizations developing or trying 

out the list should be maintained. The subconl ­

mittee also did a certain amount of thinking [n 

other areas related to hospital statistics, more 

or less on its own initiative. 

“Control” Subcommittees 

The National Committee has had only one 

“control” subcommittee so far—the Subcomm ttee on international List Revision. It has per34 
formed functions appropriate to the National 

Committee itself with respect to the Eighth Revision of the ICD, with final decision of course 

remaining in the hands of the parent Committee. 

Working Procedures and Records 

Subcommittees, like the National Committee 

itself, are not operating agencies. Thus subcommittees cannot directly conduct research, although 

they may stimulate it, and individual members 

may do research for a subcommittee: 

When a subcommittee is c“&sidering subjects 

that vequire new data or pilot studies befove 

definitive recommendations can be reached, its 

prog’ress would be dependent on obtaining a secvetayiat from an operating agency with overZapping inteyests, or on having Subcommittee 

members stimulate studies in their own organizations. It was recognized that these possibilities do not always em”st. On certain issues, a 

subcommittee might be able to do no more than 

point up the problem, an approach for dealing 

with it, and suggest a course of action. The National Committee, in t?wn, might vefer the problem to the pvoper agency or organization for 

consideration and in some instances it may be 

of assistance in secw-ing necessary funds 

through appropriate channels. (ref. 135, p. 1) 

Following the same line of thinking, a subcommittee cannot accept grants, although individual 

members of a subcommittee may (ref. 136, p. 2). 

“A questionnaire sent out in the name of the 

Subcommittee must be cleared through the usual 

government channels, ” but individual members 

of subcommittees may circulate questiomaires 

according to their own procedures (ref. 137, pp. 

1-2). 

At the same time, the following principles 

were enunciated in the Committee’s early policy 

statement: 

Within the scope of thei~ assignment, the subcommittees shall be free to function according 

to their best judgment. 

The subcommittees shatl have the authority to 

work with any other national OY international 

groups concerned with similar problems, but 

the initial contact with such organization+ shall 

be made thvough the secyetavy [of the Nationul 

Committee]. (9-ef. 7, p. 12) 

Subcommittees have not been unduly restricted 

in conducting their studies, or in getting outside 

cooperation, by the rather bare prospect of research money they have had to face. 

Subcommittees do not have secretaries according to any particular pattern and have differed widely in arranging for minutes. In some 

cases, the secretary is definitely identified either 

as being a member of the subcommittee or, in at 

least two instances, a well-equipped nonmember. 

In many instances, the function was performed 

anonymously, and possibly at some distance in 

time ikom the meeting, as for example by the 

chairman. 

Relations Between the C.ammittee 

and its Subcommittees 

The Committee’s policy statement says that 

“each subcommittee will report the status of its 

activities at least twice a year, ” with responsibility lodged with the subcommittee chairman 

unless it has been otherwise delegated (ref. 7, 

p. 12). 

Publication of subcommittee reports is a 

responsibility of the National Committee, but 

it was within the province of the subcommittee 

to use its report as a working document to be 

cimulated freely in any way desirable in forwarding the wovk of the subcommittee. (ref. 81, 

p. 1) 

The Committee has not hesitated to edit subcommittee reports, sometimes rather drastically, 

or to turn them back to subcommittees after 

making technical recommendations. 

35 
APPENDIX


GINS OF THE NATIONAL COMMITTEE SYSTEM


Of the many recommendations adopted by 

the First World Health Assembly at its meeting 

in Geneva in June-July 1948, “perhaps the most 

interesting and far-reaching . . . was that all 

governments should establish national committees 

on vital and health statistics” (ref. 2, p. 114). 

To understand the novelty and importance of this 

pattern for cooperation in international public 

health, it will be helpful to trace the rise of 

interest in the study of disease as a problem, 

not merely in the life of individuals, but in the 

life of populations. 

The first systematic concern with disease 

as a population problem— with public health, that 

is to say—was pioneered in the late 17th century 

by John Graunt. Graunt studied the mortality 

essentially of a single city over a considerable 

period, during and between plagues; by analyzing 

London’s death records he established many 

epidemiological conclusions that are still of 

interest (ref. 138). While the records themselves 

testify to genuine concern in an important public 

health problem, little actually was done toward 

using them constructively, and the records were 

not meaningful to people living elsewhere. 

There were indeed difficulties in using the 

bills of mortality for comparative studies in 

public health, as Graunt himself pointed out. 

In the words of William Farr, writing not quite 

200 years later than Graunt: 

Each disease has, in many instances, been denoted by three or four te~ms, and each teym has 

been applied to as many different diseases: 

vague, inconvenient names have been employed, 

or complications have been registered instead 

of pvimayy diseases. (vef. 139) 

Farr was of the opinion that several classifications of diseases “may . . . be used with advantage”; the medical practitioner, the pathologist, the anatomist or physiologist, the medical 

jurist “may legitimately classify the diseases and 

the causes of death in the way that he thinks best 

adapted to facilitate his inquiries, and to yield 

general results” (ref. 140). That Farr’s position 

was eclectic is shown by the rather descriptive 

nature of his own classification, which was 

organized into five groups: 

Epidemic diseases


Constitutional (general) diseases


Local diseases arranged according to anatomi­


cal site


Developmental diseases


Diseases that are the direct resultofviolence


(ref. 8, p. xi)


This classification, as likewise the somewhal 

later classification of Dr. Jacques Bertillon 

which together have so greatly affected the ICD 

was guided mainly by descriptive considerations, 

With the backing of the General Register 

Office, Farr labored to improve the classification 

and to gain international acceptance of its use. 

Although he was supported by the existing international statistical organization, which sponsorec 

revisions in 1855, 1864, 1874, 1880, and 1886, tht, 

classification never came into general use. Following Farr, Dr. Bertillon in 1893 prepared : 

new classification, based on one used by thtt 

city of Paris which synthesized English, German, 

and Swiss classifications. This list gained :. 

measure of general support since it was adopted 

by several countries and many cities, and in 

1898 was endorsed by the American Public Health 

Association. 

At this stage, therefore, Bertillon’s classification had statistical and some general public 

health backing and had secured some national 

acceptance. In 1900 the French Government wa,; 

encouraged to convoke the first International 

Conference for revision of Bertillon’s classifica ­

tion, which thus became the International List 

of Causes of Death. Other such conferences wer: . 

held under Bertillon’s leadership in 1909 an i 

1920. After his death in 1922 the revisions wer; 

continued in 1929 and 1938 under the sponsorshi ? 

of the international statistical organization an ~ 

representatives of the Health Organization of th a 

36 
League of Nations. At this point neither governmental nor nongovernmental national public health 

interests were directly involved. 

Over this period, however, the international 

significance of the classification was greatly 

extended, including of course its use by many 

countries, and a number of efforts had been 

made to develop a similar list of morbid conditions. These all 

failed to receive general acceptance, chieji!y 

because they pvovided only a limited” expansion 

of the basic cause-of-death list. The 1938 Conference . . . adopteda resolution ur@ngthat the 

various national lists in use be brought into line 

with the structure of the International List of 

Causes of Death. . . . The Conference further 

recommended that the United States Government continue its studies of the statistical treatment of joint causes of death. (ref. 1, p. 16) 

The resulting United States Committee on Joint 

Causes of Death included among its members 

and consultants experts from the United Kingdom, 

Canada, and the Health Section of the League of 

Nations. 

It will be noted that the line of thinking followed by the Committee supported the view that 

the classification of sickness ad injuyy is 

closely linked with the classification of causes 

of death. The view that such lists are fundamentally di~eyent arises from the erroneous 

belief that the International List is a classification of tevminal causes, whereas it is in fact 

based upon the tnoybid condition which initiated 

the train of events ultimately resulting in death. 

(ref. 8, p. xix) 

The Committee accordingly drafted a single list 

for use in coding both mortality and morbidity. 

The remarkable effectiveness of the committee on joint causes of death was due on the 

one hand to its broad interpretation of its mission and on the other to the fact that it made 

extraordinarily effective use of national as well as 

international experience in the course of its 

deliberations. One of, the experts who was most 

active in the work of the committee was Dr. 

Halbert L. Dunn, Chief of the National Office 

of Vital Statistics, U.S. Public Health Service. 

After discussing the achievements of the committee in an article written some years later, 

Dr. Dunn continued: 

The confe~ence participants were impyessed 

by the success of this activity. A@er clearing 

other items on the agenda, the conference addyessed itself to the question of whether some 

of the other problems in the fields of vital and 

health statistics should be handled in a similar 

manner. Obviously, if this were to be done, the 

conference would have to request nutions to 

undertake such actions, since international pYo ­

tocol whld be necessary for nations to work 

on international technical problems. After considerable discussion, this led to the recommendation that all nations should designute national 

committees to woyk on problems of an international nature which were of particular concern 

to them. (Yef. 141, p. 159) 

The Sixth International Conference for the 

Revision of the International Classification of 

Diseases which was inaugurated in 1948 

marked the beginnirg of a new era in international vital and health statistics. Apart J20m 

approving a comprehensive list for both mortality and morbidity and agreeing on international rides for selecting the imderlying cause 

of death, it recommended the adoption of a comprehensive programme of international cooperation in the field of vital and health statistics. An impoytant item in this programme was 

the Recommendation that governments establish 

national committees on vital and health statistics for the purpose of co-ovdinating the statistical activities {n the country, and to serve as 

a link between the national statistical institutions and the World Health Organization. It was 

further envisaged that such nutional committees 

would either singly OY in co-opevation with othey 

national committees, study statistical pvoblems 

of public health importance and make the results of theiv investigation available to WHO. 

(ref. 8, p. xxi) 

37 
---

---

REFERENCES 

The following abbreviations are used except when a term is spelled 

out in a reference title. Unless otherwise indicate% references to subcommittees apply to working groups of the U.S. National Committee. 

GRO--- General Register Office, Great Britain 

HS---- Expert Committee on Health Statistics, World Health Organization 

ICD--- Sub-Committee on Classification of Diseases, Expert Committee on Health Statistics, World Health Organization 

MNs	 Advisory Committee on Medical Nomenclature and Statistics 

[to General Register Office, Great Britain] 

NC---- U.S. National Committee on Vital and Health Statistics (When 

NC is preceded by “Dec. ” and followed by a number, the reference is to a document in NC files.) 

NCHS-- National uenter for Health Statistics 

NOVS-- National Office of Vital Statistics, U.S. Public Health Service 

PHs--- U.S. Public Health Service, Department of Health, Education, 

and Welfare 

WHO	 World Health Organization (WHO documents are referenced 

according to WHO usage. For example, WHO/HS/ICD/50 signifies Document 50, Sub-Committee on [International] Clas ­

sification of Diseases, Expert Committee on Health Statistics, 

World Health Organization.) 

lThe Sixth Decennial Revision of the International Lists 

of Dkeases and Causes of Death. NOVS, Vital Stati8tics–Specia2 Reports 33(2):13-47, Nov. 26, 1948. 

%owards better health statistics. Chron. IVOW Hlth.Org. 

~6):109-116, June 1946. 

3NC:	 The Untted States NationaZ Committee on Vital and 

Health Statistics. Oct. 1949. 

4---:	 Summary Mkutes of First Meeting, February 2, 1949. 

Dec. NC 4. 

5NC: Functions and Policies of the National Committee on 

Vital and Health Statistics ~’Working Draft’~. Dec. 

NC 2. Feb. 2, 1949. 

6---:	 Functions and Policies of the National Committee on 

Vital and Health Statistics. Dec. NC 5. Feb. 21,1949. 

7---:	 The First Annual Report of the United States National 

Committee on Vital and Health Statistics, 1950. PHS 

Pub. No. 40. Washington. U.S. Government Printing 

Office, Oct. 1950. 

8WHO: Manual of the [ntern&ional Statistical CkY8ification of Diseases, Injuries, and Causes of Death, Baaed 

on the Recommendations of the Seventh Revision L’onjerence, 1955. Geneva. WHO, 1957. 

‘---:	 Improvement of statistics on foetal mortality. Chron. 

World Hlth.Org. 4(6):172-176, June 1950. 

10ICD: Minutes of Meeting, “NOV. 13-21, 1961. WHO/HW 

ICD/22. Geneva. WHO. 

llYerushalmy, J., and Bierman, J. M.: Major problems in fetal 

mortality. Obst. & Gynec.Surw. 7(1):1-34, Feb. 1952. 

Reprinted as NOVS, Vital Statistics-Special Reports 

33(13):217-236, May 22, 1952. 

12NC:	 Recommendations for the improvement of fetal death 

statistics. Pub. Health Rep. 70(11): 1049-1056, Nov. 

1955. 

13Ad Hoc Subcommittee on Study of Comparability of Occupation Reporting on Census and Vital Records: Report 

~raf~. Dec. NC 146. Nov. 6,1953. 

38 
14NC:	 Summary Minutes of the Fourteenth Meeting, May 23, 

1955. DOC. NC 189. 

15---:	 SummaryMinutes of Sixth Meeting, January 26, 1951. 

Dec. NC 57. 

16---:	 National vital statistics needs. NOVS, Vitat Stati.stics-Specia? Eeprwts 45(11):219-269, July 17, 1957. 

17---:	 Improving national divorce statistics. NOVS, Vital 

Statistics-Special Reports 47(13):401-426, June 25, 

1962. 

18Temporary Sub-Committee for Consideration of the Problem 

of Case Registers: Report. Dec. NC 8. July 14, 1949. 

19HS: Third report, part I, Conference on Morbidity Statistics. 

Tech. Rep.Ser. lVZd Hlth Org., No. 53. Geneva. WHO, 

July 1952. 

‘NC:	 Summary Minutes of the Thirteenth Meeting, May 14, 

1954. DOC. NC 163. 

21Subcommittee on a Glossary for Morbidity and Medical Care 

Statistics: SummaryMinutes of the First Meeting, January 19, 1955. Dec. NC 180. 

gg---:	 Findings and Recommendations on Scope of a Glossary. Dec. NC 193. Oct. 1955. 

23---: Final Report. Dec. NC 206. Mar., 15, 1956. 

24Subcommittee on Morbidity Statistics: Report. DOG NC 19. 

Dec. 16, 1949. 

26.4d Hoc Subcommittee on Morbidity Statistics: Report. Dec. 

NC 47. Oct. 6, 1950. 

26NC: ProposaZ for Collection of Data on Illness and[mpairments, United States, A Report of the Subcommittee 

on National Morbidity Survey. PIIS Pub. No. 333. 

Washington, D.C. Oct. 1953. 

27 Subcommittee on Hospital Statistics: Report. Dec. NC 80. 

Sept. 4, 1951. 

28HR Report on the second session, Annex 3–Subcommittee 

on Hospital Stati sties, report on the first session: 

Tech. Rep.Ser. WZd HZth Org., No. 25. Geneva. WHO, 

Oct. 1950. Originally appeared as WHO/HS7Hosp. 

Stat. /7. 

---:	 Report of the Third Session of the WHO Expert Committee on Health Statistics, November 21-29, 1951. 

WHO/HS/32. Geneva. WHO, Dec. 14, 1951. Reprinted 

as Dec. NC 86, Jan. 15, 1952. 

30Subcommitwe on Hospital Statistics: Using hospital morbidity data to study morbidity in communities. Hospita2s 27(9):115-122, Sept. 1953. 

31Amcmican Medical Association: Standard Nomenclature of 

Diseases and Operations, ed. 4, R. J. Plunkett and 

A. C. Hayden, eds. Philadelphia. Blackiston Co., 

19.52. 

32 Efficiency in hospital indexing of the coding system of the 

International Statistical Classification and Standard 

Nomenclature of Diseases and Operations. Journal of 

the American Association of Medical Record Librarians 

30(3), June 1959. 

331ntemational Classification of Diseases, Adapted for Indexing Hospital Records by Diseases and Operations, 

2 VOIS., rev. ed. PHS Pub. No. 719. NCHS. Washington. U.S. Government Printing Office, Dec. 1962. 

34NC:	 Hospital Statistics and the U.S. National Health Survey. Dec. NC 313. Oct. 15, 1959. 

3%S: WHO/HS/Nat.Com./7. Mar. 19, 1951. 

36---: WHO/HS/Nat.Com. /2O. Nov. 21, 1951. 

370 fficial Report of the United States Delegation to the International Conference for the Seventh Revision of the 

International Lists of Diseases and Causes of Death, 

Feb. 21-26, 1955. Reproduced by NOVS, Mar- 25, 

1955. 

38HS: Draft, Classification of Causes of Injury Proposed for 

the Use of the Armed Forces. WHO/HS/Nat.Com. /l59. 

Geneva. WHO, Jan. 9, 1964. 

39Subcommittee on Milita~ Health Statistics: Report. DOC. 

NC 150. NOV. 1953. 

40NC:	 Summary Minutes of the Twelfth Meeting, November 

20, 1953. Dec. NC 154. 

41---:	 Summa~ Minutes of the Thirtieth Meeting, November 

16, 1962. DOC. NC 383. 

42Subcommittee on Classification of Mental Disorders: Draft 

Classification of Mental Dkorders. Unnumbered document in file of working documents for 28th meeting of 

NC, Dec. NC 364. See also Draft Classification of 

Mental Disorders, Dec. NC 366, Oct. 9, 1961. 

43NC:	 Summary Minutes of Twenty-eighth Meeting, October 

30, 1961. DOC. NC 364. 

44NC Sub-Committee on Classification of Mental Wlsorders: 

Draft Classification of Mental Disorders. WHO/EfS/ 

ICD/17.Annex 1. Geneva. WHO, Nov. 9, 1961. 

45GR0 Paper M.N.S. (M)29, Annex 1. Sept. 26, 1962. 

461CD: Report on the Proposals for the Revision of the Statistical Classification of Mental Disorders. WHO/HS/ 

ICD/40. Geneva. WHO, Oct. 8, 1963. 

47NC: Revision Proposal of Classification of Mental Disorders. Dec. NC 410. Oct. 18, 1963. 

48HS: Second Report [October 30-November 6,1963, meeting]. 

WHO/HS/ICD/50. Geneva. WHO, Feb. 4, 1964. 

49Expert Committee on Mental Health: Report on the first 

session. Tech. Rep.Ser. Wld Hlth Org., No. 9. Geneva. 

WHO, May 1950. 

50---:	 Epidemiology of mental disorders- Tech.Rep.Ser. Wld 

Hlth Org., No. 185. Geneva. WHO, 1960. 

39 

29 
511CD: Glossary of Mental Disorders. WHO/HS/ICD/45. 

Geneva. WHO, Oct. 17, 1963. 

52NCHS: Hear t d“sease ; in adults, United States, 1960-1962. 

Vital and Hea2th Statistics. PHS Pub. No. 1000-Series 11-No. 6. Wasbingtorr. U.S. Government Printing 

Office, Sept. 1964. 

53Weiner, L., et al.: Use of multiple causes in the classifi54For 

cation of deaths from cardiovascular-renal disease. 

Am.J.Pub.Heatth 45(4):492-501, Apr. 1955. 

defense of “combination categories, ” see American 

Publio Health Association, ~ommittee on Medical 

Certification of Causes of Death, Statistics Section: 

Probleme in the medical certification of causes of 

death. Ara.J.Pub.Hea2th 48(1):71-80, Jan. 1958. For 

Dr. Dom’s views, see Subcommittee on International 

List Revision: Summary Minutes of Third Meeting, May 

22, 1962. Dec. NC 372. The discussion between the 

United Kingdom and United States experts is reflected 

in: (a) GRO, MNS, Sub-Committee on Classification 

of CardiovascularD is eases: Paper h4.N. S. (V)66. Sept. 

30, 1963. (b) NC: Summary of US-UK Discussion on 

Cardiovascular Disease Classification. Dec. NC 399. 

Sept. 3, 1963. (c) NC: Present Status of WHO Proposal on Combination Categories. Dec. NC 419. Mar. 

26, 1964. 

55Subcommittee on Classification of Congenital MaIfonnations: Summary Minutes of First Meeting, November 

29, 1961. DOC. NC 367. 

56---:	 Summary Minutes of Second Meeting, March 9, 1962. 

f)oc.NC 369. 

57-. -:	 Alphabetical Index rkrDraft Classification of Congenital Defects. Dec. NC 381. 

58---:	 Comments on Draft Classification of Congenital Defects. Dec. NC 384. Feb. 15, 1963. 

59NC:	 SummarY Minutes of Thirty-second Meeting, Octiber 

14, 1963. f)oc.NC 411. 

60Status of Revision Proposals on the International Classification of Diseases. Dec. NC 404. Oct. 1, 1963. 

611CD: 111. Endocrine sys~m, Nutritional and Metabolic Diseasee. WHO/HS/ICD/50 Add. 11. Geneva. WHO, 

June 9, 1964. 

62 NC: Annual Report, Fiscal 1955. Dec. NC 197. 

63---: Annual Report, Fiscal Year Ending June 30, 1956. 

64Suhcommittee on Classification of Causes of Fetal Death: 

Report. Dec. NC 238. June 7, 1957. 

65NC: Summary Minutes of the Nineteenth fifeeting, June 14, 

1957. DOC. NC 241. 

66AMA Committee on Maternal and Child Care: A Guide for 

the Study of Perinatal MortaZity andhiorbidity. Chicago. 

American Medical Association, 1959. 

67Subc6mmitteeon Classification of Causes of Perinatal Mor 

bidity and Mortality: Draft of Classification of Carises 

of Death of Fetuses and Infants Under One Year. Dec. 

NC 266. June 3, 1958. 

68 ---:	 General Information on Sample Used in Testing Pernatal Classification. Dec. NC 272. Aug. 6, 1958. 

69---:	 Explanatory Notss for Coding Causes of Fetal and Ir ­

fant Death. Dec. NC 273. Aug. 6, 1958. 

70 ---:	 Code Sheet–Causes of Fetal and Infant Death. Dot. 

NC 274. Aug. 6, 1958. 

71 ---:	 Explanatory Notes for Coding Conditions Relating h, 

Fetuses and Livelmm. Dec. NC 275. Aug. 6, 1958, 

72---:	 Code Sheet–Morbid Conditions. DOG. NC 276. Aug 

13, 1958. 

73.	 --: Summary Minutes of Eighth Meeting, September 29, 

1960. DOG. NC 339. 

74 ---: Revised Draft Classification. Dec. NC 34o. 

75 ---:	 Additional Comments on Draft Classi fi cation of Cause: ( 

of Morbidity and Mortality Peculiar to tbe Fetal anti 

Early Infancy Periods. Dec. NC 345. May 9, 1961 

76---:	 Certain Causes of Morbidity and Mortality Peculiar k, 

Fetal and Early Infancy Periods. Dec. NC 351. Jurr(, 

6, 1961. 

77NOVS Death rates by age, race, and sex, United States 

1900-1953, accidente, except motor-vehicle. Vita, 

Statietice–Special Reports 43(29):447-461, Aug. 21 

1956. 

78NCHS: Vi$af, Statistic of the United States, 1963, Vol. 11 

Part A. Washington. U.S. Government Printing Office 

1965. 

79---:	 Typee of injuries, incidence and associated disabil 

ity, United States, July 1957-June 1961. Vital anL’ 

Health Statistics. PHS Pub. No. 1000-Series 1O-NO. 

8.	 Washington. U.S. Government Printing Office, Apr 

1964. 

80NC: Summav Minutes Thirty-first Meeting, Mav 17, 1963 

Dec. NC 395. 

81. -.: SummaW Minutes of the Ninth Meeting,November 6 

1952. DOG. NC 103. 

82Subcommittee on PhYsical Impairment Code: Questionnaire 

DOG. NC 111. 

83---: Interim Report. Dec. NC 112. Mar. 1953. 

84NC:	 summary Minutes of the Eleventh Meeting, June 12 

1953. DOC. NC 126. 

85H& General Aspects of the Eighth Revision
 of the Inter 

national Classification of Diseases, by WHO unit o. 

the International Classification of Diseases and De 

velopment of Health Statistical Services. WHO/HS,’ 

ICD/5. Geneva. WHO, Oct. 20, 1961. 

40 
86corbe~~, H, Go, WHO cent~~f~rcla~~ifi~ation of Diseases: 

Structure of the International Classification of Diseases in Relation tn Short Lists. WHO/HS\ICD/10. 

Geneva. WHO, Oct. 19, 1961. 

871CD: Progress Report No. 2-S&cture of the Classification in Relation to Short Lists. WHO/HS/ICD/24. 

Geneva. WHO, Mar. 15, 1963: 

‘%ubcomrnittee on Physical Impairment Code: Progress Report. DOG. NC 186. hiay 18, 1955. 

09---:	 A Proposed System for Coding Physical and Mental 

Impairments. Unnumbered document. 1955. 

90NC:	 Summary Minutes of the Fifteenth Meeting, October 31, 

1965. Dec. NC 195. 

01 ---:	 Summary Minutes of the Seventeenth Meeting, September 28, 1956. DOC. Nc 220. 

%ubcomrnittee on Physical Impairment Code: Report of Conference, Dec. NC 213. Sept. 15, 1956. 

~SNC: summary Minutes of the Twenty-fifth Meeting, June s, 

1960. f)oc. NC 341. 

94 ---:	 Summary Minutee of the Twenty-ninth Meeting, May 25, 

1962. DOC. NC 378. 

9ii...: -

Summary Minutes of the Twenty-sixth Meeting, January 

9, 1961. DOC. NC 344. 

96 .--:	 Summary Minutes of Fourth Meeting, June 19, 1950. 

Dec. NC 34. 

97 ---:	 Summary Minutes of Third Meeting, December 16, 1949. 

Dot, NC !21. 

98 Subcommittee on Statistics Needed Concerning Fertility: 

Report. Dec. NC 40. Oct. 5, 1950. 

‘gNC!: Summary Minutes of Fifth Meeting, October 15, 1950. 

Dec. NC 49. 

100Subcommittee on Statistics Needed Concerning Fertility: 

Report. Dec. NC 75. Aug. 1951. 

10INC:	 Statistics needed concerning fertility. NOVS, Vital 

Statisr2cs-Specir.zZ Reports 33(11):193-202, Feb. 25, 

1952. 

102Subcommittee on Fertility and Population Statistics: Report. Dec. NC 191. Oct. 20, 1955. 

103NC: Progress in development of fertility statistics and 

population eetimatee. NOVS, Vital Statistics-Speciat Reports 39(8)432-442, May 14, 1956. 

104 ---: Summary Minutes of the Twentieth Meeting, December 

6, 1957. DCC. NC 255. 

105...:	 Fertility etudiee based on data for the 1960 census 

period. NOVS, Vital Statistics-Special Reports 47(5): 

145-157, June 8, 1959, 

106---: Summary Minutes of the Twenty-second Meeting, November 14, 1958. DOC. NC 291. 

107Subcommittee on Fertility Measuremerrti First Meeting, 

May 23-24, 1963. Dec. NC 400. 

108--.: Final Report. Dec. NC 417. Mar. 30, 1964. 

109NC:	 Summary Minutes of Thirty-third Meeting, April 13, 

1964. DOC. NC 422. 

llOSubcommittee on Fertility Measurement Report. Dec. NC 

431. Feb. 15, 1964. 

lllNC:	 Summary Minutes of the Twenty-first Meeting, June 6, 

1958. l)oc. NC 268. 

112Subcommittee on Fertility and Population Statistics: Providing Birth Statistics on a Current Basis. Dec. NC 

287. NOV. 4, 1958. 

113---:	 A Current Birth Sample Program. DOC. NC 334. June 

6, 1960. 

ll%C:	 Summary Minutes of the Twenty-fourth Meeting, January 29, 1960. Dec. NC 321. 

115. -.:	 The Need for a Quinquennial Census. DOC. NC 333. 

June 2, 1960. 

116- --:	 Medical Certification of Medico legal Cases. PHS Pub. 

No. 810. Washington. U.S. Government Printing Office, Nov. 1960. First appeared as Dec. NC 306. 

117Subcommittee on Medical. Certification of Medicolegal 

Cases: Report [first draft]. Dec. NC 222. Jan. 24, 

1957. 

~18---:	 Summary Minutes of the Third Meeting, Feburary 8, 

1957. DOC. NC 234. 

119---: Final Report. Dec. NC 243. May 23, 1958. 

120---:	 Analysis of Comments Returned on Report. DOC. NC 

2S3. Oct. 23, 1958. 

121.. -:	 Verbatim Comments on the Draft Report. Dec. NC 298. 

Feb. 25, 1959. 

122NC:	 Summary Minutes of the Twenty-third meeting, June 

15, 1959. Dec. NC 310. 

123---:	 Summary Minutes of tbe Twenty-seventh Meeting, June 

19, 1961. DOC. NC 356. 

124Subcommittee on Statistics Available From Medicolegal 

Deaths: Summary Minutes of First Meeting, September 

26, 1963. DOC. NC 407. 

125 ---:	 Research Potential of the Study of Medicolegal Deaths 

[final reportl. Dec. 414. Mar. 30,1964. 

126 Subcommittee on Quantification of Welhress: Minutes of 

Third Meeting, March 23, 1959. Dec. NC 303. 

127---;	 Minutes of Second Meeting, January 26, 1959. DOCNC 297. 

128 ---:	 Minutes of Fourth Meeting, May 25, 1959. Unnumbered 

document in NC files. 

129---: Final Report. Dec. NC 343. Dec. 1960. 

41 
13!NC: Annual Report, Fiscal Year, 1962. 

131Subcommitbe on Health Economics: Summary Minutee of 

the First Meeting, July 17, 1961. Dec. NC 357. 

132---:	 Summary Minutes of the Second Meeting, October 16-

17, 1961. f)oc.NC 363. 

133NC:	 United States Statistics on Medicolegal Economics, 

Present Status and Recommendations for Additional 

Data. PHS Pub. No. 1125. Waehingtcm. U.S. GovernmentPrinting Office, Jan. 1964. 

134---:	 SummaryMinutes of the Tenth Meeting, March 6, 1953. 

Dec. NC 113. 

13%ubcommittee on Causes of Fetal Death: Minutes of the 

Third Meeting, Oct.ober 26-27, 1952. Unnumbered document in NC files, considered at9thmeetingof NC, 

Dec. NC 103. 

136NC:	 Summary Minutes of the Seventh Meeting, September 

14, 1951. Dec. NC 82. 

~o~ 

137---:	 Summary Minutes of the Eighth Meeting, April 16,1952. 

DOC. NC 96. 

138Graunt, J.: Naturat and Political Obsemations Mentioned 

in a Following Index, and Mode Upon the Bills of Mortality. 1662. 

139Registrar General of England and Wales: First Annual Report. 1839. p. 99. Quoted from WHO:Manual of the 

International Classification of Diseases, Injuries, and 

Causes of Deathj Based on the Recommendations of 

the Seventh Revision Conference, 1955. Geneva. WHO, 

1957. 

140---:	 Sixteenth Annual Report. 1856. Appendix, pp. 75-76. 

Quoted from WHO:hfanuul of the Intemai!ionai Classification of Diseases, Injuries, and Causes of Death, 

Based on the Recommendations of the Seventh Revision Conference, 1955. Geneva. WHO, 1957. 

141Dunn, H. L.: Objectives underlying future patterns of work 

of national commitkes on vital and health statistics. 

Btdt. Wld Htth Org. 11:147-162, 1954. 

42 
OUTLINE OF REPORT SERIES FOR VITAL AND HEALTH STATISTICS 

Public Health Service Publication No. 1000 

SeYies 1.	 P~og~ams and collection pvoceduyes. — 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 

Se)-ies 2.	 Rata evaluation and methods vesea~ch. —Studies of new statistical methodology including: experimental 

tests of new survey methods, studies of vital statistics collection methods, new analytical techniques, 

objective evaluations of reliability of collected data, contributions to statistical theory. 

Reports number I -1-

SeVies 3.	 Analytical studies. —Reports presenting analytical or interpretive studies based on vital and health statistics, carrying the anal ysis further than the expository types of reports in the other series. 

Reports number 1-4 

SeYies 4.	 Documents and comwuttee ~epovts. -~inal 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 numhcr 1-i 

Scvies 10,	 Data Fvom the Health Inten,iew Suv~ey .—Statistics on illness, accidental injuries, disability, use of 

hospital, medical, dental, and other services, and other health-related topics, hosed on data collected in 

a continuing national household interview survey. 

Reports number I -32 

Series 11.	 Data Fvom the Health .Examination Suvuey .—Statistics based on the direct examination, testing, and 

measurement of national samples of the population, including the medically defined prevalence of specific diseases. and distxihutions of the population with respect to various physical, physiological, and 

psychological measurements. 

Reports number 1-16 

Sevies 12.	 Data From the Health Recovds Sumey. — 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 numbc r I -4 

Series 20.	 Dataon mortality. —Various statistics on mortality other than as included in annual or monthly reports— 

special analyses by cause of death, age, and other demographic variables, also geographic and time 

series analyses. 

Repo]ts number 1 ,lml 2 

SeYies 21.	 Data on natality, maviage, and divorce. —Various statistics on natality, marriage, and divorce 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-q 

SeYies 22. Data From the National Natality and Mortality Sumeys. —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, 

characteristics of pregnancy, etc. 

Reports number 1 ,]nd 2 

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