CHAPTER XIV

THE CLASSIFICATION OF MENTAL DISEASES

When the American Psychiatric Association first approached the problem of formulating a definite scheme for the collection of statistical data relating to mental diseases it was immediately confronted with the necessity of adopting an official classification of psychoses purely for purposes of uniformity. This undertaking, which suggested no difficulties at the outset, led to all kinds of unexpected complications and embarrassments. Classifications of "insanity" are almost as old as the terms mania and melancholia and have been given a grossly exaggerated importance by the space which for so many years has been devoted to a consideration of this subject in textbooks. This, if nothing else, appears to have been demonstrated quite clearly by the discussions of the last few years.

A review of the literature of psychiatry shows that attempts to classify the psychoses date back almost to the beginning of medical history. Hippocrates is said to have recognized three forms of mental disorders—mania, melancholia and dementia, although there is some question as to his having used those terms in accordance with their present significance. Celsus[130] also described three forms of insanity. The first, which was accompanied by febrile symptoms, he termed phrenitis. The second was characterized by sadness and caused by black bile. The third was accompanied in some cases by false images, while in others the whole mind or judgment was impaired. The Roman law divided the dementes or mad into two classes, the excited or violent (furiosi) and those deficient in intellect (menti capti). Aretaeus[131] discussed mania, melancholia and dementia, apparently regarding them as all manifestations of some one disease process. Melancholia, he said, "does not affect all the faculties of the mind; the patients are sad and dismayed; they are without fever." He described it as only an initial stage of mania. Caelius Aurelianus[132] did not regard melancholia as a form of insanity, "from which disease it differs in that the stomach chiefly suffers, while in Madness it is the head." Galen in his writings referred to amentia or dementia, imbecility, mania and melancholia.

In the sixteenth century Felix Plater[133] devised the following classification: 1. Mentis imbecillitas: Hebetudo, tarditus, oblivio, imprudentia. 2. Mentis consternatio: Somnus immodicus, carus, lethargus, apoplexia, epilepsia, convulsio, catalepsis, ecstasis. 3. Mentis alienatio: Stultitas, temulentia, amor, melancholia, hypochondriacus morbus, mania, hydrophobia, phrenitis, saltus viti. 4. Mentis defatigatio: Vigiles, insomnia. Linnaeus[134] in 1763 called his fifth class of diseases Mentales, divided into three orders: Ideales, Imaginarii and Pathetici. Sauvages in the same year included Hallucinationes, Morositates and Deliria under the heading of Vesaniae in his "Nosologia Methodica." Vogel[134] in 1764 divided Paranoiae into mania, melancholia, and amentia. Cullen in 1772 included insanity or the Vesaniae in the neuroses, divided into four groups—Amentia, Melancholia, Mania and Oneirodinia. He described eight varieties of melancholia and three of mania. Oneirodinia included somnambulism and nightmare. According to Jelliffe, Plocquet described six varieties of delirium in his treatise on paranoia in 1772. Pinel in 1791 limited himself to four classes of insanity—mania, melancholia, dementia and idiotism. He looked upon melancholia as a delirium exclusively directed upon one object or series of objects and accompanied by sadness. Idiotism was an advanced form of dementia. Esquirol in 1838 modified Pinel's scheme somewhat and described Lypemania, Monomania, Mania, Dementia and Imbecility or Idiocy. The active discussion of classifications of various kinds led Pritchard[135] to make the following interesting comment in 1822: "I cannot conceive anything more preposterously absurd than the attempt to classify diseases with all the divisions and technology of a botanical or zoological system, and to force what is essentially disorder and confusion to assume the appearance of that order and symmetry which nature displays in the arrangement of the organized world. An aetiological classification is the only mode of terminology and arrangement that can be of any practical advantage, and that is all that we have to consult." He nevertheless published a classification of his own which was essentially psychological in principle, although containing nothing new.

The German school of this time was exceedingly prolific in the production of classifications, as will be shown by the following interesting and elaborate scheme of Flemming's[136] published in 1844:—

FAMILY-AMENTIA—MENTAL DISEASES

_First Group_—Infirmitas (Feeblemindedness).

Varieties:

A. According to etiology: 1. Inf. primaria, or congenita (Idiocy) 2. Inf. secundaria, or acquisita (Imbecility) a. Inf. e. morbo (Brain injuries, encephalitis, epilepsy, etc.) b. Inf. senilis

B. According to degree: 1. Inf. adstricta, or partial feeblemindedness (Weakness of a single mental faculty) a. Dysmnesia (weakness of memory) b. Inf. adstr. surdo-mutorum (feeblemindedness of the deaf and dumb) c. Inf. adstr. coecorum (feeblemindedness of the blind) 2. Inf. sparsa—General (absolute or relative weakness of general mental faculties)

_Second Group_—Vesania. _First Order_:—Dysthymodes or Dysthymia.

Varieties:

A. According to types: 1. Dys. transitoria or subita (acute) 2. Dys. continua (chronic) 3. Dys. remittens (remittent)

B. According to degree: 1. Dys. adstricta (limited or partial) a. Dys. atra (melancholia or lypemania) 1. Homesickness. 2. Ferocitas et morositas ebriosorum (Alcoholic excitement and ill humor) b. Dys. candida (cheerful dysthymia or melancholia hilaris) c. Dys. mutabilis (changeable or alternating) 2. Dys. sparsa (apathica)—General dysthymia (melancholia attonita).

_Second Order_:—Vesania anoëtos or Anoësia—Deliria of various forms.

Varieties:

A. According to types: 1. Anoësia transitoria or subita (acute) Species: a. A. e febre—fever delirium b. A. e potu—alcoholism c. A. ex affectu—affective d. A. semisomnis—confusion of drunken sleep e. A. Somnambula—somnambulism 2. Anoësia continua—chronic 3. Anoësia remittens—remittent.

B. According to degree: 1. Anoësia adstricta—partial or limited a. A. ad sensationes—hallucinatory delirium b. A. ad cogitationes—delusional delirium 2. Anoësia sparsa—general a. Delirium tremens

_Third Order_:—Vesania Maniaca (Mania).

Varieties:

A. According to types: 1. Mania transitoria or subita—acute a. M. s. a febre—encephalitic delirium b. M. s. a potu—alcoholic mania c. M. s. ex affectu—affective mania d. M. s. e partu—puerperal mania e. M. s. e mordo occulto—amentia occulta, which includes the above forms. 2. Mania continua—chronic mania 3. Mania remittens—remittent mania

B. According to degree: 1. Mania adstricta seu instinctiva—partial or limited mania. (Mania sine delirio of Pinel.) (Moral insanity, monomania.) 2. Mania sparsa—general mania.

This is said to have been based on Jacobi's somato-aetiological theory (1830) that "there is no disease of the mind existing as such, but that insanity exists solely as the consequence of disease, either functional or organic, in some parts of the body system." Heinroth[137] saw in the various mental disorders a disturbance of one or the other of the normal functions of the mind which he divided into three classes. "If the cause of derangement is in relation to one of these manifestations of mental existence—and to one or another it must belong, since the mind is ever occupied with phenomena related to one out of the three classes—we have only to inquire to which modification the disorder actually refers itself, or whether it affects the feelings, the understanding, or the will. Since one of these has possession of our consciousness, or is at least predominant at every point of time, whichever function of the mind happens to be that which is falling into disorder, by it the form of insanity is determined." Griesinger[138] in 1845, on the other hand, was of the opinion that all classifications must in the end return to the principal forms previously described—mania, melancholia and dementia. In 1860 Morel announced his well-known classification: Hereditary Insanity, which included imbecility and idiocy; Toxic Insanity (alcohol, lead, mercury, etc., as well as cretinism); Insanity produced by the transformation of other diseases (hysterical, epileptic, hypochondriacal); Idiopathic Insanity (general paresis, etc.); Sympathetic Insanity, and Dementia, "a terminative state."

Maudsley spoke of Affective or Pathetic, and Ideational Insanity. The former was divided into maniacal perversion, melancholic depression and moral alienation. The latter included general forms (mania or melancholia), partial forms (monomania or melancholia), dementia (primary and secondary), general paralysis and imbecility. Régis described five forms of mania, five of melancholia, two of insanity of double form, and a systematized progressive insanity. In addition to these, he divided constitutional insanity into two groups—the degeneracy of evolution and the degeneracy of involution. Krafft-Ebing[139] included melancholia, mania, primary dementia, exhaustion psychoses and terminal conditions in his group of psychoneuroses. Under the heading of degenerative forms he described constitutional affective insanity, paranoia and periodical insanity. Neurasthenic, epileptic, hysterical and hypochondriacal psychoses were grouped together under the constitutional neuroses. In addition to this he described chronic intoxications, organic brain diseases and arrested development. At a meeting of the International Congress of Alienists in 1889 the following classification was adopted: 1. Mania; 2. Melancholia; 3. Periodical Insanity; 4. Progressive Systematical Insanity; 5. Dementia; 6. Organic and Senile Dementia; 7. General Paralysis; 8. Insane Neurosis (hysteria, epilepsy, hypochondriasis, etc.); 9. Toxic Insanity; 10. Moral and Impulsive Insanity; and 11. Idiocy. Ziehen[140] had a classification scheme which represented an advance in some respects. Mania and melancholia were described as affective psychoses, and paranoia as an intellectual disorder. He also referred to mixed or combined forms. Imbecility, general paresis, terminal deteriorations, etc., were grouped together under the general heading of psychoses with intellectual defects.

The British Medico-Psychological Association has had an official classification for many years. This was quoted by Savage[141] in 1907 as follows:—

1. Congenital or infantile mental deficiency (idiocy or imbecility) occurring as early in life as it can be observed: (1) Intellectual a. Without epilepsy b. With epilepsy (2) Moral 2. Insanity arising later in life: (1) Insanity with epilepsy (2) General paralysis of the insane (3) Insanity with the grosser brain lesions (4) Acute delirium (acute delirious mania) (5) Confusional insanity (6) Stupor (7) Primary dementia (8) Mania a. Recent b. Chronic