classification of mental diseases - semantic scholar · 32 art. iii.?the classification of mental...

32

Art. III.?THE CLASSIFICATION OF MENTAL

DISEASES.

BY W. II. 0. SANKEY, M.D. LOND., F.R.C.P.

Tiiere was a time when a classification of diseases occupied the attention of physicians in nearly every country. Cullen, Mason Good, in this country; Linnseus, Boerhaave, Sauvages, abroad, spent much labour in trying to bring the somewhat for- midable catalogue of diseases of their day into a system. That their efforts were futile is not extraordinary, since the knowledge of diseases was imperfect, and the opinions relative to them constantly changing.

The aim, however, of these eminent men was to systematise medicine, and to bring it into the same order as other branches of natural science. In these days we scarcely aim at doing more than to make a provisional arrangement. We use classification merely to facilitate the study of disease, or as a kind of memorici technica to assist us in obtaining a wider grasp of facts. Facts accumulate; they must be grouped so as to enable us to have a general view of the whole in mass, and to be able afterwards to study the characters which constitute the dif-

ferences between the individuals, and to retain them in our

memory. There have been numerous proposals for grouping or classi-

fying the various cases of insanity. Fresh systems are constantly proposed. Some of those most recently brought forward have met with a much more favourable reception than I should be disposed to give them, as none of them appear to me to answer the purpose of bringing into groups the cases according to the real nosology. Of course, any basis may be selected for dividing or grouping different objects; but it is quite obvious that the product will depend very much for its character upon the nature of the basis that is selected. We may classify plants, for example, into herbs, trees, and shrubs; our classes, thus formed, would merely give us the habits of the plants classified, not the kind of plants. We might arrange all trees into the evergreen and deciduous; this would only give us a result in the vernation, and would not convey to us any knowledge of the species, unless it could be shown that the vernation was always allied with certain essential characters of the individual plant. We might with diseases classify them according to the ages and sexes of the patients; but, of course, this would give no assistance to us in nosology.

THE CLASSIFICATION OF MENTAL DISEASES. 33

It is for similar reasons, I think, that many of the most

newly proposed systems for grouping mental diseases have proved unsatisfactory. They have not been founded upon the essential characters of the disease itself.

By the word " disease" I mean the sum of all the phenomena

which are observed in a given case, including the first indica-

tions of deviation from health, the evolution of the symptoms, their progress, order of succession,

and mode of termination.

One recent proposition for a classification of mental diseases was based upon causes. If it could be shown that all the

phenomena of the disease invariably followed a given course when resulting from a given cause, and

such cause was single then a classification, based on etiology, would not be objection- able ; but as this cannot be done, the

basis is bad, and the

classification must result in failure, as shown abundantly by Dr.

Crichton Browne in his criticism of Dr. Skae s classification, which is avowedly based on etiology.

If, however, the relation of a known cause could be shown to

be direct and absolute, I will admit that it would be a mere

quibble to object to an etiological classification, though the real

subject to be classed is the effect and not the cause?the pheno-

mena or symptoms, and not their producer. Such an immediate

cause could only be the actual pathological change in the system; but this, though at present an object

for research, is in no in-

stance an actual achievement, and, therefore, not at present available. Directly we apply ourselves to a

more indirect cause,

or to the remote causes, we have a multitude of secondary

agencies, the operation of each of which would form an impos-

sible problem. , ..

Dr. Skae's so-called classification, however, was really no

classification at all, for it grouped nothing, and was, in fact, a mere list of supposed operating causes.

Dr. Batty uke classi-

fied Dr. Skae's so-called species of disease; but what is the result ??a classification of causes, not diseases.

But in the attempt to group what are called mental diseases,

there is another difficulty which meets us on the threshold. the

group itself is not founded on any nosological base. The term

includes not a class of diseases, but rather such sort of medical

cases as are met with in asylum practice. ^

And, indeed, it is

with such that I have in view to deal with in the present paper, or, in other words, to arrange the

cases usually met with in

asylums into groups, according to the nature of the maladies.

It is sufficiently confusing, certainly, for anyone, even a

well-qualified medical man, on first entering a large asylum, to observe the great diversity of cases, and the variety of mental

symptoms which present themselves. And, indeed, the cases PART I. VOL. III.?NEW SERIES. C

34 THE CLASSIFICATION OF MENTAL DISEASES.

vary greatly in many ways, not only in the mental symptoms, but in the stages of the disease, the ages of the subjects, and their condition generally. A teacher must, for the purpose of elucidation, group those various cases, so that a general view of the whole may be the more readily grasped by the student. He must not only throw into groups the cases themselves, but he must do the same for the symptoms. The classification which, after some twelve years of experience as a teacher, I have found convenient, is the following. In forming it, I have aimed to make it as simple and yet as comprehensive as I could, for I think it is important that the divisions should be as few as may be compatible with completeness. Little is gained indeed, when the classes are nearly as numerous as the objects that are to be grouped. And by making the first divisions sufficiently comprehensive, it is easy to subdivide them afterwards.

In taking, therefore, a general survey of all the cases in any asylum, I think we may readily divide them into two grand divisions, viz.:?

It will be found that the disease in some is really idiopathic; in other terms, it is distinct from all other known forms of disease ; while, on the other hand, in the rest of the cases the mental symptoms are only a part of some other well-

recognised malady, such as epilepsy, or organic disease of the brain, and in which there happens to be much disturbance of the mental faculties. In the former cases the mental aberration is an attribute; in the latter, an accident in the course of the disease.

We have thus two grand divisions, viz., Division A, in which the mental symptoms are primary, or essential, or idiopathic ; and B, in which they are secondary, or symptomatic.

This grand division (A), or the purely mental cases, may be further divided into two subdivisions, viz. (a), in which the cases depend upon a purely pathological change, or on what is

really disease; and (6), in which the mental symptoms are due rather to developmental causes.

In the former catagory (a) I can recognise as yet but two species morbi, viz.:?

I. Ordinary insanity; and II. General paresis. In the subdivision (6) there are also two kinds of cases :

(1), in which the developmental anomaly is an original con- formation, or idiocy; and (2), in which it is due to decay, or senile imbecility.

This forms, therefore, the classification of all the cases of

primary, or idiopathic, insanity, and which may be clearer in the form of a table.


Class A.?Idiopathic Disease.

Subdivision (a)?Pathological: 1. Insanity proper. 2. General paresis.

Subdivision (b)?Developmental : 1. Idiocy. 2. Senile decay.

The Division B?in which the mental phenomena are only symptomatic, or accidents in the cases forms, perhaps, a

smaller moiety of the inmates of asylums, and the most fre-

quently occurring kind of cases are the four following :

I. Epileptic insanity. II. Alcoholismus. III. Spinal disease, extending to

the cerebral regions.

IV. Organic disease of brain, as the result of apoplexy, etc etc

In explanation of these, I will add a few notes.

I. With regard to the epileptic cases, they are met with in two forms: (1) In which the subject is imbecile, and sent to

the asylum for care. (2) In which the patient is dangerous and

violent. But since either state is not necessarily present in

cases of epilepsy, the mental symptoms are no essential part of

II. With respect to the cases of Alcoholismus, these are to

be found in asylums, also in two forms: (1) In acute stage or

delirium tremens, less frequently sent to asy.ums, than (.) chronic alcoholic poisoning, which is generally to be met in most establishments. These cases resemble occasionally general

paresis; but the diagnosis is easily made, and the prognosis

widely different. The alcoholic poison is attended with well-

marked symptoms, and must not be confounded with a tendency

to intemperance which is present in other description of cases.

III. The spinal disease. The term is here employed as a

general name for various cases of motor affections, whether

ataxy or paralysis, and in which the cerebrum is also involved.

In many of such cases there is a degree of mental imbecility, or

mental disturbance, or motor affections of the speech, which

make them resemble more or less closely the idiopathic disease, general paresis, but yet, with care, may be distinctly dif-

ferentiated; and since in these the duration of the malady is

much greater than in general paresis, the diagnosis is lm-

portant. .

IV. Organic disease of the bram. I he term was employed

by the French Commission appointed to classify mental

diseases, and it signifies those cases which are dependent on c 2

36 THE CLASSIFICATION OP MENTAL DISEASES.

various organic diseases of the brain, as tumours, softening, results of apoplexy, etc. etc., in which the patient is imbecile, irritable, dysphasic, or partially paralysed, and is therefore sent into the wards of our asylums.

Besides the above, there may, in different asylums, and in other countries, be few other forms of disease attended with delirium as a symptom: as leprosy, etc.

My table is therefore as below.

i f Morbid IL Inaanity ProPer- (A).?Idiopathic '<

' ' '

j 2- General paresis. 2. [ Developmental {4;

(B).?Symptomatic .

5. Epileptic insanity. 6. Alcoholismus. 7. Spinal diseases. 8. Or cranio cases.

And this corresponds very closely to the result arrived at

by the International Committee at Paris. It will be seen that I admit but two forms or species of

disease. This may need some explanation: firstly, why I limit them to two; and secondly^ why I consider that those two are distinct.

The first question has already been forestalled. Bv the term "a disease" we mean a certain series of changes all

emanating from a given pathological condition, and I believe all known varieties in the symptoms belong to but two ; and with regard to the second question, or why I consider ordinary insanity specifically distinct from general paresis, I would state my own conclusions.

Without going so far as to say that the difference between the two kinds of mental disease in species is absolutely demon- strated, yet I think the evidence is much stronger for such a

conclusion than the opposite; and this is almost generally admitted in the present day. The symptoms are not only somewhat different, but undoubtedly they follow a different

course from the commencement to the termination. The natural history of the two cases seems to me to point to the following difference in pathology.

In every mental act, or act of cerebration, there are two chief agencies in operation: 1st, the nerve tissues; 2nd, the blood supply. A careful consideration of the early symptoms tends to show that one disease commences through the first of these agencies, the second through the other. To illustrate

this as briefly as possible, I will point to the well-observed fact that the acts of cerebration can be distinctly affected through


the blood, as by the injection of certain substances into the

veins, and by the introduction of substances, as alcohol, into the system by the stomach; and that while one agent will produce one effect, another agent causes a different result; and in most of these, according to the quality of the agent employed, the effect is more or less transient.

It is equally well known that disturbances of the digestion

produce a depressing effect on the system. Now, the early stage of ordinary insanity very closely

resembles such a con-

dition. 1. In nearly every case well marked symptoms of

impaired digestion are present, and are the first to appear such

as capricious appetite, loaded tongue, flatulence, anxious feeling

located at the prsecordia, constipation, etc., all which point to

an error in the process of blood-making, though, as the mental

symptoms increase, these may be lost sight of by the patient.

2. And the mental symptoms at first closely resemble those of

impaired digestion. The patient is said to be hipped ; he is dull, fidgetty, or listless, not disposed to exert himself, etc. Like

Hamlet, he loses all his mirth and foregoes all customary exer-

cise. As much as this occurs commonly, and is not infrequently

dissipated by a dose of medicine, there is no distinctive mark

to separate these cases from the onset of ordinaiy insanity in

its first or melancholic stage. Though the spirits are depressed and the patient is restless or apathetic,

he is able to reason or

form as correct a judgment as formerly, if roused to do so; and

in decided cases of melancholia the reasoning acuities, the

memory, and intellect proper remain quite intact or years even,

and become involved only at a very late period, while the rest

of the nerve functions, the functions of sensation, motion, &c. are

not changed beyond a sense of fidgettiness and restlessness or

in the opposite condition, as dulness and want of energy. In

fact, the case seems an exaggerated condition of a very common

kind of dyspepsia. , . , . ,

In such a case the change is not in kind but in degree of

ordinary action. The state is often very slight and transient, removed by easy means; all of which points to a shifting or transient course; and in considering the nerve element and the blood condition we must conclude it is to the latter which is

liable to most frequent variation. A still closer examination,

for which I have not space here, corroborates the conclusion

that it is to the blood and blood supply that cases of ordinary insanity are primarily due.

If, on the other hand, we trace a typical case of general paresis, we can trace from the commencement, or from a very early period, symptoms which embrace every artificial division of nerve force.

38 the classification' of mental diseases.

In very many cases the attack may be traced to a great nerve shock, a fright, a moral shock, an astounding event, a great grief, and even a great joy. Certainly, in that very difficult search for originating causes of the attack, such are decidedly frequent. A great nerve disturbance seems to be the

origin of the general disturbance. Thus, in looking at the effects, they point to the entirety of the nerve functions?to intellect, emotions, volitions, to involuntary and what used to be called the sympathetic system, or the nerves of organic control; and at first all is excitement; and then soon all is feebleness.

Briefly, the intellect rambles wildly, the conversation is rapid, ideas crowd upon the mind?they deal chiefly in immensity. The actions are violent in the extreme, and without control or

order; the affections are wildly excited; the patient is moved to mirth, or to sympathy and tears; he is generous: believes

himself omnipotent, etc.; the pupils are irregular; the sexual

passion unrestrained. This having endured awhile, the converse commences: the intellect becomes imbecile; the movements

feeble ; and enervation commences, and gradually involves every faculty in increasing palsy. There is evidence here of a nerve shock ; first of a nerve excitement, and then nerve paresis, which affects the sensation, the intellect, the self-controlling processes, the movements as well as the regulating powers presiding over organic life.

There is, in fine, no similarity between the two descriptions of the phenomena during life. There are also great differences in the history, the age and sex liable, the degree of heredity, as well as in morbid anatomy, and which I have examined in detail in a paper published in the "Journal of Mental Science," vol. ix. p. 467.

In my table, including only two species of actual mental disease, it will be observed that many of the almost innumer- able varieties discribed in the textbooks are as' yet quite un- accounted for?as mania, melancholia, etc. But many of these

so-called diseases are but sj^mptoms, and often but passing symptoms, in the course of a disease; and many of the phenomena thus promoted to the position of a distinct disease not only are transient, but suceed each other in the progress of a single case. Our specialty is much separated from general medicine, but we cannot claim to have separate rules of nosology. A disease does not change its essential characters during its progress; as it commences so it continues; it may have well-marked stages, but we cannot suppose that each stage is a distinct species of disease. We mean, in fact, by the word disease, a certain order of morbid phenomena. The study of medicine consists in observing the development, the evolution, and natural cause of these

phenomena.


It will be found, I think, that many of the so-called varieties of mental disease owe their title to certain stages through which a case of ordinary insanity passes : that the names denote the

phenomena of a stage only, and not of separate disease. As

ordinary insanity is much less fatal of the two species, and its duration, therefore, usually much more extended, it is the stages of this form which have been most frequently considered fresh species.

A case of ordinary insanity, at its first outset, commences

by a stage of melancholy, which is at fix*st considered as acute

melancholy. The case has in this stage four modes of termina-

tion?(1) in recovery; (2) in death ; (3) in passing into mania ; (4) in becoming chronic (chronic melancholia). When, in its

evolution, it becomes mania, it has been falsely called a new disease. This stage, too, or acute mania, has various

modes of

termination?(1) in cure; (2) to death; and (3) to chronicity ;

in the last category it has received various names, as chronic mania, delusional insanity, incoherence, etc. It often occurs

that when the disease becomes chronic, the violence of the

mania abates, and so after a time do the melancholic

symptoms of chronic melancholia; thus the case becomes one of chronic insanity, probably with delusions, incoheience, etc.

In this stage both recovery and death are less common, and

death would probably be due to some accidental cause, lather than the disease itself.

When the case has reached this stage, the depression or elation of the spirits, and the condition of melancholy and mania, may alternate periodically; and this, indeed, is found

more or less

marked in the majority of the cases; the alternation, too, is

sometimes on alternate days; at times on alternate weeks, months, or longer; thus we obtain a condition which the French have called manie a double forme; in certain of the cases, also, between the mania and the melancholic period, there is a state of comparative neutrality, etc., or a lucid interval.

W e have, then, what the French have called folie circulaire', but the condition is continuous with the former stages of one disease, and, therefore, cannot be considered a separate species ; and out of these symptoms we have no ground for making a fresh disease. All these cases have a natural tendency towards imbecility and dementia, which form the last stage. The following diagram will represent the stages and progress which a case of ordinary insanity may take:?


diagram of the evolution of insanity proper. DIAGRAM OF THE EVOLUTION OF INSANITY PROPER.


Thus in the natural course or progress of one malady we have certain variations in the symptoms; and it is quite true that, at one stage, the same case may present a very different character from that found in a different stage: but we cannot leave out of the consideration the history. Undoubtedly the course of a single case extends over much time?years often?but no consideration of the duration if the phenomena are continuous

can make a single case into two. Even though the commencement was in one man's experience and the end in his descendant s, the natural history of the case must commence with the commencement of the symptoms. In the histories of cases of

insanity, however, this rule has been by no means constantly

followed. In taking up the description of any so-called forms of insanity in the text-books, it will

be observed that the history has been seldom even alluded to. Each condition is studied

singly, without reference to what has gone^ befoie or what is

likely to follow. Such a mode has greatly impeded the study and comprehension of the subject.

It is almost impossible to bear in mind the large number

of names that have been thus introduced into the subject, some derived from one feature and some from another. ^

There are

upwards of forty names in Dr. Skae s list. Guistain wrote of

twenty-eight varieties of mania only, but he acknowledged that

they were assez lourde pour la memoire. ^ _

The use of certain terms is convenient, it is true, to denote

various groups of symptoms, as mania, melancholia, etc. It

is desirable to have terms which are easily understood, as signi- fying groups of facts, as morbid apprehensions, incoherence, illusion; but to treat such as separate forms of disease, and to

classify them as if they were distinct or separate diseases, is unwarrantable.

The stages also of an ordinary case may conveniently be noted

by separate names, as chronic mania, imbecility, folie circulaire; but it should be well understood that these are meiely general terms to denote a group of phenomena.

But if the whole sum of mental disease is thus reducible to

two, it will, perhaps, be asked what is the nature of those cases

met with under very familiar terms. Some of the most gene-

rally used are probably the following: 1. Puerperal mania. 2. Phthisical mania.

3. Oino-mania, or dipsomania (mania a potu). 4. Suicidal mania.

5. Homicidal mania.

6. Syphilitic mania. 7. Moral insanity.


8. Religious melancholy. 9. Suicidal melancholy.

10. Melancholy, with stupor. 11. Melancholia agitans. 12. Nymphomania. 13. Kleptomania.

The first-named appears to be at the present day that which is considered the most distinct, and to be the most widely admitted as a separate species; but, judged by the ordinary rules of nosology, there is nothing in any of these cases which should constitute them a distinct species morbi. What favours such a view is simply that the attack occurs during the puerperal condition?that is, either during pregnancy, at childbirth, or after parturition; but such coincidence establishes nothing, nor can it give a reason for making it a separate disease any more than, if a woman were to fall and break her leg in that state, the fracture would be classed as a different kind from other

fractures. Certainly the puerperal condition occurs frequently enough in the sex to make it probable that an attack of insanity should occur contemporaneously. The puerperal condition is, besides, a great change in the system of the patient, so that in a female liable to insanity it is not surprising that this condition should act as an exciting cause; and since the majority of the cases occur at or immediately after parturition, there is, besides, the great strain on the system and large loss of blood, producing anaemia, which would co-operate. But though we find cases of insanity common at such times, and more frequently than at other periods, still the occurrence of a disease at a particular time is not a sufficient ground for placing such cases in a

different position in nosology, unless it could be shown that

the phenomena?that is, the symptoms and their progress and termination?were distinct and different. A fracture or a dis-

location is the same whether occasioned by a fall or a blow : an

anaemia is the same whether produced by a bleeding from one source or another.

I have sought for a distinctive character in these cases of so

styled puerperal insanity, and have never found any. I had

1,000 women under my care at Hanwell. I had many cases

necessarily in which the disease dated from the puerperal condition. I had cases of acute insanity going on to mania. One

such case I published in a series that I gave in the British Medical Journal. I had cases which were well marked cases

of general paresis ; one which was a case of recurrent insanity. There were cases which recovered rapidly; others which passed gradually into imbecility ; others in which the patient became a chronic lunatic, with fixed delusions; but there was nothing


that I could discover of a distinctive character in the symptoms, progress, or termination from other cases.

These puerperal cases are met with also as instances of recurrent insanity. In fact, in those cases of chronic insanity in which the lucid interval is sufficiently marked, and of sufficient duration, that the patient is said to have a distinct interval of perfect sanity, the occurrence of a pregnancy or parturition is a sufficient disturbing cause to induce a distinct recurrence of mental disturbance. Many such have a fresh attack of insanity at each parturition.

This is of sufficient importance in the history of insanity generally to require mention in all systematic treatises; but there is not such an uniformity in the symptoms, nor such a difference from other cases, to constitute these attacks a separate disease. At the most, the puerperal condition is merely a disturbing element, which must be borne in mind.

With regard to phthisical mania, the same remarks are ap- plicable. Phthisis is found in insane patients. It may com-

plicate the symptoms. I have lately had several cases of

phthisis in lunatics. One an imbecile for upwards of 20 }rears ; one a female, with melancholy with stupor; the third, acute insanity, commencing with the usual melancholic stage, with suicidal propensity, going on to mania, and then to recovery. In this case the phthisical symptoms were almost in abeyance during the mental attack. Another occurred in a gentleman with chronic insanity with delusions. In these four cases there was not the least peculiarity in the mental symptoms from other cases, and they were in different stages of the disease, and in different state.

Oino-mania, &c.?This symptom is observed in different

cases, and under different circumstances. Uncontrollable desire for drink is sometimes a vice, some-

times is more allied to imbecility, or idiocy, and sometimes it is a symptom in recurrent insanity. The term is also used for the condition produced by alcohol, or alcohol poisoning.

A person whose desire for strong drink is uncontrolled, may be one whose resolution is feeble, or whose desire is abnormally strong. Such a condition then is simply a vice.

His control, however, may be destroyed by disease, as is often the case in the first stage of general paresis. The excess of drink is then a result, not a cause of disease; and in all of the above circumstances the symptoms cannot be called the essential character of the disease, but simply an accident during its course.

Lastly, in some secondary attacks of recurrent insanity, or chronic insanity, the outbreak is manifested by an uncontrollable desire to drink.


Homicidal, Suicidal Mania, (See.?The secondary attack, in some cases, is ushered in by an outbreak of violence, by a murderous attack on another, by a suicidal attempt, by a desire to burn, to do an act of violence of some other kind, quite as frequently as by an uncontrollable desire for strong drink; but inasmuch as the morbid propensity is simply a phenomenon of the outbreak, and is by no means always of the same kind in the same patient in his different attacks, the simple mode of recurrence cannot separate these cases from the other cases of recurrent insanity. When the recurrence of the disease has been shown by drinking, it has been called dipsomania; when it has been by a murderous attack in another, it has been called homicidal mania. If the outbreak is an act of immorality, it has been called by some who indulge in nomenclature, moral insanity; for similar reasons another case has been styled nymphomania, or kleptomania, according as the propensity of the patient is in one or other direction.

But nearly all these, which are merely ordinary symptoms of disease, occur at times in the course of a primary attack: as the suicidal propensity, in an attack of acute insanity, in the melancholic stage ; nymphomania also in an early stage; while kleptomania is a common symptom in the early stage of general paresis.

I do not wish to maintain that no other species of insanity may not yet be eliminated; but at present, as far as my experience and examination have extended, only two have been actually proved.

classification of mental diseases - semantic scholar · 32 art. iii.?the classification of mental...

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