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The Epileptic Psychoses correspond with the A. M.-P. A.'s group 17—Epileptic Psychoses, and 22—the Not Insane group of epilepsy without psychosis. Again the A. M.-P. A.'s distinction seems to be founded upon the question of committability and not upon the very possibly more important therapeutic lines of distinction. Epilepsy is placed early in this pragmatic ordering of groups, because in practice it appears to me that epilepsy is so often forgotten and also because the clinical history of epilepsy or epileptoid states is often so relatively good compared with the clinical history of sundry other symptoms given us by lay witnesses.
Again, I have lumped in my pragmatic ordering the alcoholic, drug and poison psychoses, because the question as to their occurrence can be lodged practically in a single sentence. The A. M.-P. A.'s groups 9 and 10 roughly correspond with what I have termed the Pharmacopsychoses. (Nomenclature is not here in question, but it would appear that the Greek term in the first half of the word “Pharmacopsychoses” corresponds pretty exactly with both the alcohol and drugs involved in this group and the poisons there specified.)
The next fusion process in group V, which I have termed the Encephalopsychoses, may seem a good deal more questionable to the practical worker, but I consider that a group which takes into account those neurological signs which we think of under
A, signs of heightened intracranial pressure, and
B, signs of reflex asymmetry, and the like, is a practical grouping. This group is in fact the neurologist's group. The technique of determining the focal brain lesion group of psychoses is the technique of determining the existence of focal brain lesions which are partly responsible for or are indicators of the cause of the mental symptoms, in a given case. I here lump the A. M.-P. A.'s group 1–Traumatic Psychoses, group 3—Psychoses with Cerebral Arteriosclerosis, group 6-Psychoses with Huntington's Chorea, group 7–Psychoses with Brain Tumor, and the larger part of group 8Psychoses with other Brain or Nervous Disease (excluding Tabes).
It seems to me that the practical decision whether a case belongs in any one of these five A. M.-P. A.'s groups depends upon the neurologist's clinical technique and largely upon whether the neurologist can find signs of heightened intracranial pressure or signs of reflex disorder, asymmetry, and the like. It seems to me that the process of getting at the question whether such an encephalopsychosis is traumatic, arteriosclerotic, neoplastic, etc., is a question logically subsequent to the decision that the case belongs in the group as a whole. It may be inquired whether general paresis and cerebral syphilitic psychoses ought not to be classified as Encephalopsychoses. It is true that from one etiological point of view, they might well be so classified; but we are not here attempting an etiological classification. We are trying to make a pragmatic classification that shall be of practical diagnostic and therapeutic value. There can be no question that from the standpoint of therapeutics, it is decidedly important to eliminate logically the question of syphilis before we come to deal with other forms of encephalic disease producing psychosis. The same principle of order in diagnosis may now be applied of course to the sub-groups or genera in the Encephalopsychoses, and some arguments in this direction have been given in the paper above mentioned “Genera in Certain Great Groups or Orders of Mental Disease." But to proceed to the more general ordering. Having gotten rid of the syphilitic mental diseases, the almost (in some form) omnipresent question of feeble-mindedness, the hardly less frequent question of some epileptic or epileptoid condition or equivalent, having disposed of the alcohol, drug and poison question, having applied the neurologist's technique and eliminated such matters as heightened intracranial pressure and reflex asymmetry, in what order shall we consider the remainder of psychiatric nosology?
Practically, I feel that the next question is that which the internist might best solve, and for this purpose I would group together, A. M.-P. A.'s group 12—Psychoses with other Somatic Disease, with its seven sub-groups, and group 11–Psychoses with Pellagra. I have given some arguments for the order in which these sub-heads under the Symptomatic Psychoses, group VI, might well be considered, in the paper above mentioned.
Having now put out of the way the internist's contribution, how shall we attack the numerically smaller, but logically more difficult residuum ? Practically, I think at this point one should try to eliminate all the involutional, presenile, and senile questions. As
for involution-melancholia itself, it is possibly of little moment whether it be classified under the presenile and senile group or under the manic-depressive group. We shall get the entity out in any event by our orderly approach. With some misgivings, I have, however, preferred to place the involution-melancholia group below with the Manic-Depressive Psychoses, leaving the other presenile psychoses to be grouped with the senile ones. It is of special value in this method of attack that we have pulled so far apart the arteriosclerotic conditions from the senile ones.
We now approach the most difficult questions. I would practically place the schizophrenic question ahead of the cyclothymic question, because it seems to me that dementia præcox symptoms blanket manic-depressive symptoms from a diagnostic standpoint. Otherwise expressed, is it not in general true that practically any psychopath may show at times the characteristic mania or depression of the cyclothymic, but is it at all so true that characteristic dementia præcox symptoms appear in every form of mental disease? That schizophrenic symptoms do so appear, in the midst of, e. g., manic-depressive psychosis, at least occasionally and as a rule singly, cannot be denied. But that any characteristic constellation of schizophrenic symptoms appears in any other disease than dementia præcox must be regarded as very doubtful.
Having then eliminated schizophrenia, that is, A. M.-P. A.'s group 15, and a part possibly of group 16, namely the part called “paranoic conditions ” I would then proceed to the cyclothymic conditions which appear in the A. M.-P. A.'s classification as group 13-Manic Depressive Psychoses, and group 14-Involution Melancholia.
It seems to me that in practical discussion in early phases of mental disease, it is very salutary to fuse the question of ManicDepressive Psychosis and Involution Melancholia, so that the diagnostic disputant might present to his audience all the phenomena that he thinks are cyclothymic at the outset.
We have now accounted for all the A. M.-P. A.'s groups except a portion of 16, 18, 19, and 21 and the larger part of 22. Having eliminated the cyclothymic states, I would proceed to eliminate the Psychoneuroses, group 18 of the A. M.-P. A.'s classification. Then, for my part, I cannot see any gospel for the orderly diagnosis of the remainder of the so-called entities, which appear to
me to be of a very nondescript and variegated description. For example, paranoia seems to me not to have been proved to be of schizophrenic nature, and, although some forms of it appear to resemble chronic mania that some might press into the cyclothymic division, on the whole would it not be wiser to relegate paranoia to an extremely doubtful, special and unresolved group of conditions? As with 16-Paranoia, so with 19, the A. M.-P. A.'s group of Psychoses with Constitutional Psychopathic Inferiority, this phrase means much and little. It has successfully borne an enormous weight in the matter of exclusion of certain immigrants. It is doubtless of great value in the matter of recruits. It is an ore for future psychiatric mining ; but for my part I would not like to make the diagnosis until I had excluded all the previous ten great groups that I have just mentioned.
Of course, the undiagnosed psychoses, the A. M.-P. A.'s group 21, also belong in my chosen “ragbag" group in, and there might appear 22d-Constitutional Psychopathic Inferiority without Psychosis, and 22f “others to be specified.”
From the general results of this analysis, would it not be possible to say that the A. M.-P. A.'s classification, relatively successful as it is from the standpoint of a reference table for statistical purposes, and relatively successful as it may be in representing a reputable German etiological ordering, can be used with a certain readjustment in a practical orderly manner for the purpose of pragmatic diagnosis, having in mind special treatment and management as its aim? In short, may we not use this classification of the A. M.-P. A. like many others, by throwing its groups and subordinate clinical types into pragmatic groups arranged in key form, following the practical standards of, e. g., Gray's Botany"?
We thus arrive at the following general considerations concerning the recent American classifications in psychiatry:
1. There is an extraordinary unanimity on the part of American psychiatrists as to the constituents of psychiatric nosology and this despite a number of nomenclatural divergences.
2. The classification proposed by the American Medico-Psychological Association and adopted by the United States Government for practical war work is a suitable reference table for statistical purposes of the major groups and clinical types of mental disease.
3. The classification may be somewhat inadequate for the purpose of general and psychopathic hospital practice, but a slight revamping might resolve this difficulty.
4. The American Medico-Psychological Association's classification appears to follow an etiological ordering borrowed ultimately from reputable German sources, and this etiological ordering is a good one if a certain etiological viewpoint is in mind.
5. The question is raised, Whether it would not be better to order the groups and types of mental disease in a pragmatic rather than a theoretical order, that is, in an order having therapy in mind rather than an order having etiology in mind ?
6. The writer proposes such a pragmatic order of certain great groups or orders of mental disease, corresponding with the botanical or zoological orders.
7. The writer finds that the 22 American Medico-Psychological Association's groups might well be compressed for practical purposes of diagnosis into II groups. He finds that the clinical types subordinated to the great groups of the American Medico-Psychological Association's classification correspond more or less accurately to the genera of a botanical or zoological classification, and proposes that in practice these sub-groups be considered in order, in general accordance with the principles of botanical or zoological taxonomies.
8. This question of how to use a classification may be defined as the question of a key to the grouping of diseases. The key question is entirely independent of the classification or referencetable of entities and entity groups, and both the key question and the classification-list question are independent of questions of nomenclature and terminology. Moreover, the writer would insist that the logical process of diagnosis per exclusionem in ordine here developed has nothing whatever to do with the order in which data can or should be collected.