are now moving. The yeast is working, too, in the INSANITY VERSUS MENTAL DISEASES National Conference of Social Work; and just as "charities and correction" has fused and crystallized THE DUTY OF THE GENERAL PRACTITIONER into "social work," so the former committee of that IN PSYCHIATRIC DIAGNOSIS body on "feeblemindedness and insanity" has now into a committee on "mental E. SOUTHARD, M.D. crystallized hygiene." The medical man who does not some year attend a BOSTON meeting of the National Conference of Social Work4 The time has come when the general practitioner will sooner or later wake up to reckon without his must assume responsibilities new to him: he must host-—the social worker. In brief, no sign fails to become as much a psychiatrist as he is specialist in point to an increasing demand for more medical ser¬ other directions.1 But how specialistic, it may be vice, as well as for more service of every technical asked, is the general doctor-man to be? Quien sabe? sort, for the psychopath. And times change. But so much is certain: The But what exactly ought the general practitioner to general doctor-man does not know as much about do for his instruction in modern psychiatry? He psychiatry either as he should know, or as he has com- looks back at a meager training. He was by law a» mand of, let us say, pediatrics, gynecology or derma- a rule excluded for a period of years from whetting tology. Science, C. S. Peirce defined, I believe, as his mind on medicolegal problems of commitment : the range of ignorance. Well, the general practi- the law somehow permitted him to remove an appen¬ tioner's range of ignorance re psychiatry is altogether dix the moment he passed his state board examination, too wide for his own conscience's comfort and disas- but the law required experience and a partner in the trously wide for the good of society. matter of certifying insanity. Again, early in this All this can now be shouted from housetops by rea- century a flood of Teutonic verbiage overflowed the son of what the layman terms "shell shock," a problem field, and the graduate doctor who ventured inside an for medicine no less wide than the whole of clinical asylum hastily beat a retreat when Merkfähigkeit neurology and psychiatry, the field we are coming to raised up its head or Dämmerzustand closed down know as neuropsychiatry.2 But already before the over all. Of course various clearly written books shell shock alarums, the American general practitioner gave the main facts (de Fursac,5 Dercum,6 Diefen- in more than had become responsible these matters for dorf,7 Peterson,8 White,9 et al.) ; but there was little his father had to be. In 1906 the state of Michigan in the medical school memories of most men to tie at Ann had laid down its psychopathic ward Arbor these facts to, except a few curiosa of dismal asylum and control a novel in placed in of it specialist train¬ walks and some medicolegal stories too mature for ing, functions and scope. Now, it is safe to say, no the nonsocialized medical student to grasp in their state can hold up its head in a place of the highest proper relations. Am I this too dark ? honor in painting picture civilization without establishing a psycho¬ Now and then at the apex of a career some The particular pathic hospital. commonwealth of Massachu¬ outstanding man is able to prevail on medical col¬ setts, in 1912, followed the lead of Michigan. Private to him curricular time to do the endowment allowed in leagues give enough 1913 the establishment in Mary¬ topic justice ; but on the whole, even in so-called Class land of another institution in which the scientific point A medical schools, either the of committees, of ignorance view made use of physicians, psychologists and or curricular pressure, or remoteness of clinical mate¬ trained workers the lay for high modern purposes rial, or an overripe professional point of -view, has of mental hygiene. Meantime, societies for mental killed in embryo the medical student's chances of hygiene had been established,3 and doubtless others learning much about psychiatry. I Read before the Section on Nervous and Mental Diseases at the consider and propose that all general practitioners Sixty-Ninth Annual Session of the American Medical Association, who feel at a loss how to use the relics of Chicago, June, 1918. practically Because of lack of space, this article is abbreviated in The Journal. their psychiatric training or the products of their read¬ The complete article appears in the Transactions of the Section and in the author's reprints. ing in such books as the above mentioned should as 1. To show the popular interest in these topics, see any numbers, soon as at least a week in contact especially Current Bibliography, of Mental Hygiene, published quarterly possible spend with by the National Committee for Mental Hygiene, Inc., 50 Union Square, New York City. 4. Proc. National Conference of Charities and Correction, especially 2. See remarks in the Sattuck Lecture for 1918: Southard, E. E.: for 1915, Baltimore; 1916, Indianapolis; 1017, Pittsburgh; 1918. Kansas Shell Shock and After, Boston Med. and Surg. Jour., 1918, 179, 74. City (name now changed to National Conference of Social Work). 3. Connecticut, 1908; national, 1909; Illinois, 1909; New York, 1910; 5. De Fursac: Psychiatry, translated by Rosanoff, latest edition. Massachusetts, 1913; Maryland, 1913; Pennsylvania, 1913; North Car- 6. Dercum: A Clinical Manual of Mental Diseases, 1917. olina, 1913; Dayton, Ohio, 1914; District of Columbia, 1915; Alabama, 7. Diefendorf: Clinical Psychiatry: A Textbook for Students and 1915; Louisiana, 1915; California, 1915; Rhode Island, 1916; Ohio, Physicians. 1916; Tennessee, 1916; Missouri, 1916; Indiana, 1916; Iowa, 1917; 8. Peterson, in Church and Peterson: Nervous and Mental Diseases. Virginia, 1917. 9. White, W. A.: Outlines of Psychiatry.

Downloaded From: http://jama.jamanetwork.com/ by a University of Manitoba User on 06/08/2015 the clinical material of some institution like the Ann ophthalmology and otology. Up to recent times, we Arbor Psychopathic Ward, the Boston Psychopathic have not demanded from the general practitioner a Hospital, or the Henry Phipps Psychiatric Clinic at knowledge of so much about mental diseases as we Baltimore. I specify these institutions, not because have often been able to demand for diseases of Ihe the state institution men are unable to give in some skin, the ear or the eye. The time has come when instances even more valuable instruction, but because the general practitioner must assume responsibility in the specified institutions have contact with the acute, this direction. Even at the expense of postgraduate curable, incipient and dubious cases that most resemble work on the topic, the general practitioner is going to the most important psychiatric material of general fail who does not proceed to acquire a grasp on the practice. I have not thè slightest doubt that the main conceptions of psychiatry. authorities of the specified institutions would not only I have recently, for the purpose of discussion with tolerate but actually welcome the arrival of the general specialistic colleagues, gone over the textbooks and the practitioners for such study purposes. I am sure that main classifications used in institutions for the insane the general practitioner who comes for a week will want to stay a month and will certainly come back TABLE 2.—MENTAL DISEASE GROUPS (ORDERS) more. 1. Syphilitic .Sypbilopsychoses for 2. Feebleminded .Hypophrenoses 3. Epileptic .Epileptoses WHAT THE GENERAL PRACTITIONER SHOULD 4. Alcoholic, drug, poison.Pharmacopsychoses 5. Focal brain ("organic," artcriosclerotic).Encepbalopsychoses KNOW OF PSYCHIATRY 6. Bodily disease ("symptomatic").Somatopsychoses 7. Senescent, senile.Geriopsychoses I want now to sketch the main features of the 8. Dementia praecox, paraphrenic.Schizophrenoses 9. Manic-depressive, cyclothymic.Cyclothymoses psychiatric landscape as I think it should be com¬ 10. Hysteric, psychasthenic, neurasthenic.Psycboneuroses manded by the general practitioner. 11. Psychopathic, paranoiac, et al.Psychopathoses First, the to become general practitioner ought and the attention to Ameri¬ something of a psychiatrist and not in the first instance psychopathic, confining my can views.11 I find an on try to become an alienist. I am here making a some¬ extraordinary unanimity what unfamiliar distinction. In Table 1 I summarize the part of these colleagues on the subject-matter of Those of the who in parallel columns the line of distinction as I think psychiatry. general practitioners it well be drawn. occasionally dip into the specialistic literature of might mental an I recently discussed somewhat fully the intricacies and nervous disease strike into atmosphere of the column.10 The here of what must seem the most lively controversy. But foregoing parallel point in of fact the battles are localized—I rather is to ask how much of the field of mental dis¬ point greatly mean the battles the actual concerning facts. There is a ease, medically considered, general practitioner deal of nomenclatural difference still to have in his range. I suppose there can be good preserved ought in textbooks. I have been to some no doubt that the to know sundry trying put general practitioner ought order into this matter and offer in Table 2 a list of as much about as he does about relatively psychiatry the groups of mental disease which I think will the sixteen or seventeen other main of major groups topics be found the vast of that we denominate A approved by majority special¬ practical specialties. general ists.12 In fact, I do not know a who must be in that he has single specialist practitioner general actually would not that in some sense each of the sub¬ more command of all the than one of agree specialties any exists. To be sure, some the is to have the same joined groups specialists specialists likely concerning might want to split the groups up further, but of the existence of this mass of medical data there is TABLE 1.—LINE OF DISTINCTION BETWEEN really ALIENIST AND PSYCHIATRIST no doubt. I ALIENISTS PSYCHIATRISTS put into the left-hand column the everyday terms Field: Field: insanity, the insane psychiatry, the mentally for these column a diseased. groups and in the right-hand Field: public, governmental, legal Field: social, private, medical. revised and Hellenized nomenclature which I believe Field: opinion for court use Field: medical, psychologic and social diagnosis and treatment. has some worth. this Hellenized nomen¬ selective: Concerning Decisions alternative: Sanity Decisions e. g., sypliil- I wish to that in I no versus insanity itic, feebleminded, epileptic, clature, say practice would more alcoholic, coarse brain disease, of the in a school for the feeble¬ symptomatic, senescent-senile, speak hypophrenoses schizophrenic, c y c i o t h y m i c, minded than I would of the Leguminosae for dinner psychoneurotic, etc. Insanity implies mental disease Sanity consistent with mental dis¬ or the Rosaccae for a nosegay. The advantage of ease of mild degree or of spe¬ the Grecian nomenclature is cial type quite another, namely, Sanity : Insanity =: 1 : 0 Mental disease of all degrees, of the of exact which the kinds possibility definition, everyday many terms do not admit, particularly as some of them deal with The must at least have the disease entities (as dementia praecox) rather topics. general practitioner than with disease function of being able to specify the right specialist or entity groups. The contacts the specialists to call in consultation. If by chance the gen¬ practical of Boston Psychopathic eral is himself of a in Hospital with the Massachusetts profession lead me practitioner something specialist the pediatrics or certain aspects of internal diseases (and to the idea that "range of ignorance" of psychiatry can be surely every general practitioner ought to be some¬ by the general profession safely localized. Let us dismiss or thing of a specialist in some direction if only to gauge the eleventh psychopathic group of the a I am his knowledge concerning general medicine), it is so foregoing list, namely, group sometimes much the better for the fate of the particular child tempted to call the "ragbag" group of mental diseases, since the or adult whose illness is in question. But we do not psychopathias, monomanias, psychopathic demand of the general practitioner a fine capacity in personalities, etc., which, with varying nomenclature, or the the diagnosis of skin diseases of minutiae of 11. Southard, E. E.: Recent American Classifications of Mental Dis- eases (to be published in Tr. Am. Med. Psychol. Assn., 1918). 10. Southard, E. E.: Alienists and Psychiatrists: Notes on Divisions 12. Southard, E. E.: A Key to the Practical Grouping of Mental Dis- and Nomenclature of Mental Hygiene, Ment. Hyg., 1917, 1, 567. cases, Jour. Nerv. and Ment. Dis., 1918, 47, 1.

Downloaded From: http://jama.jamanetwork.com/ by a University of Manitoba User on 06/08/2015 are dropped into this group, are the regions of densest The seventh, the senile and presenile group (VII), ignorance on the part not only of general practition¬ is again a group in which the symptoms are for the ers, but also on the part of psychiatrists themselves. most part such as are easy to understand in the quan¬ Limiting consideration, then, to the ten other and titative terms of everyday life. better defined groups, I note that the first seven are But, with the enumeration of these seven groups, groups whose general features are well enough under¬ we have come to the conclusion of the list of diseases stood by the general practitioner, so that, barring mis¬ in which the symptoms are, as one might say, familiar takes in diagnosis and delays in handling, there is a and wellnigh quasinormal, following lines which the minimum of gross error on the part of the general physician can readily understand by comparison with practitioner. the phenomena of his own life. For in the three The general practitioner may not agree, nor will remaining groups, the schizophrenic (VIII), cyclothy- perhaps all of the older psychiatric specialists agree, mic (IX) and psychoneurotic (X) groups, there are that virtually every, if not every,13 case of mental dis- phenomena of such supernormal or subnormal degree ¿ase requires consideration as possibly syphilitic (I), cr of such an abnormal and dissociative nature that Nevertheless all practitioners concede that there is a a considerable specialistic study is required to unravel syphilitic group of mental disorders, some of which them. I find that many practitioners, even in haughty require intensive treatment. old Massachusetts, figuratively throw up their hands Again, with respect to the hypophrenias,14 most phy¬ when asked to define dementia praecox (here termed sicians are aware of the increasing part played by the schizophrenic) or manic-depressive (here termed diagnosis of feeblemindedness (II) in modern work cyclothymic) psychosis. with reference to As for the psychoneuroses, the attitude of some touching general practice special I the schools and juvenile courts. Though they may practitioners, though hope not too many, is that the in this are con¬ be in doubt concerning the exact value and scope of symptoms group "imaginary" and by mental tests, nevertheless the general rubric of feeble¬ sequence in some sense nonexistent. The attitude of mindedness has become familiar. So much emphasis many general practitioners to the psychoneuroses is like the attitude of the Christian scientists to disease has been laid on the higher grades of so-called feeble¬ in : the as a mindedness, on the or subnormals general psychoneuroses are regarded form, namely, "stupids" not of "mortal but of nonexistent whom it seems invidious to term "feebleminded," that perhaps error," disease which the is to be rid of a I have had no hesitation in proposing the term patient got by "hypo- process akin to exorcism. This erroneous to cover all forms of feeblemindedness, not opinion15 phrenic" on a confusion between the method of the feebleminded proper of and Cana¬ depends psy¬ merely English and the nature of or dian but also the imbeciles and idiots below the chotherapy the etiologic genetic usage, features of the Because faith feebleminded proper and the or subnormals psychoneuroses. by "stupids" mountains are moved, one has no license to consider above the feebleminded proper. that faith established the mountains in the The and the first place. epileptic group (III) group of mental the difficulties of the and are Accordingly, general practi¬ diseases due to alcohol, drugs poisons (IV), tioner in the and familiar to the and confronting schizophrenics cyclothy- reasonably general practitioner; mics on the one hand, and the on a bad mistakes be committed psychoneurotics although good many may the other, are of different sorts. The practitioner of in these the of errors commit¬ groups, yet percentage some years' standing has simply had no opportunity ted themselves in the same by psychiatric specialists to study intensively in the medical school or in post¬ groups is so high that we should not weep about gen¬ graduate work enough schizophrenics and cyclothy- eral practitioners' motes from our own specialistic mics to permit his understanding their nature. As eyes containing large beams. for the psychoneurotics (whether in the form of hys¬ The fifth group in the foregoing classification, terics, neurasthenics or psychasthenics), the general namely, that of mental disease due to focal brain practitioner is sufficiently familiar with their general disorder (V), is another group sufficiently familiar nature, having enough of them and to spare in his to the general practitioner, as also to the neurologist consulting rooms. Nevertheless, his ideas concerning whose special field it touches, and the common cate¬ them are apt, I think, to be somewhat vague, or at mental gories of symptoms found therein are likewise least vague enough to permit his many a case The calling familiar. general practitioner sees enough cases of schizophrenia or of cyclothymia erroneously a case of arteriosclerotic brain disease, of meningitis, of brain of psychoneurosis. Hence I think are about the brought tumor and like, to be familiar with the not very a number of false prognoses and a number of poor special mental effects that these brain disorders evoke. prescriptions for sanatorium treatment, treatment by Again, in his everyday capacity as a diagnostician, change of environment, or special treatment at home, the general practitioner gets a certain familiarity with when some other of these treatments than the one the sixth or internist's group of mental disorders— chosen would have been far better for the the patient. so-called symptomatic psychoses based on definite It is for no academic reason, therefore, that I ask somatic disorder (VI), such as a typhoid fever, a the general practitioner to bring himself up level with pneumonia, a puerperal exhaustion, a cardiorenai dis¬ the times in the matter of schizophrenia and cyclothy¬ ease, a dysthyroidism or even a pellagra. The symp¬ mia. I feel that if he gets an adequate notion of toms here also are such as are familiar to the general schizophrenia and cyclothymia, his already reasonably practitioner and run on the same lines as the symp¬ correct notions of the psychoneuroses will get their toms of disease in general. proper balance and perspective alongside the other I found one eminent 13. Southard, E. E., and Solomon, H. C.: Neurosyphilis: Modern psychoses. really practitioner Systematic Diagnosis and Treatment, Presented in One Hundred and denouncing the word "schizophrenia" because he had Thirty-Seven Case Histories, Boston, W. M. Leonard, 1917. 14. For this term see remarks by the writer in Tr. Am. Assn. for the 15. Southard, E. E.: Shell Shock and After, Boston Med. and Surg. Study of the Feebleminded, 1918. Jour., 1918, 1-19, especially pp. 76 and 77.

Downloaded From: http://jama.jamanetwork.com/ by a University of Manitoba User on 06/08/2015 been practicing for decades and ought really to have If I tell a layman that so-and-so is suffering from known what schizophrenia meant if there really was shell shock, the layman is aware that the term "shell any such symptom or condition. On inquiry, however, shock" connotes a great deal about the war and its I found that the eminence of this practitioner, which effects, but quickly observes that the term denotes was very genuine, had been attained in ways which little or nothing, and he is forthwith thrown back on excluded him from any knowledge of the peculiar the expert for information as to what shell shock or condition as And symptom known schizophrenia. really means and what its prognosis may be. Not so what holds for dementia praecox holds also for manic- when the ardent social worker learns that so-and-so depressive psychosis. The week's excursion to some is a victim of dementia praecox. Is she not almost psychopathic hospital or psychiatric clinic, above sug¬ entitled to think that a victim of dementia is demented to hold on the of gested, ought lay especially concepts or else is going to become demented? Are there not schizophrenia and cyclothymia ; and the attainment of similar attached to the term ? these two significances "praecox" elementary knowledge concerning groups I believe that a deal of harm has come to will the level of the knowl¬ great bring general practitioner's from the use of the term "dementia mental diseases to the level of his patients praecox," edge concerning up and most whom I have con¬ the diseases of other psychiatric specialists general knowledge concerning sulted on the with me. On this In his with the point cordially agree specialties. particular, practice early account I have felt that the of the Swiss cases, cases which he sees often earlier than does the proposal Bleuler16 use the clinic, will be psychiatrist to the term "schizophrenia" psychopathic hospitaPor psychiatric for cases to the dissociation found in benefited and his efforts at psy¬ subject peculiar tremendously thereby, these cases is a one. The a will not be wasted on schizo¬ good fact that it has peculiar chotherapy measurably sound, novel to medical ears of the last phrenics and cyclothymics, but will be concentrated on generation, the genuine psychoneurotics. is no good reason for denouncing the term "schizo¬ since the of the disease are at If one thinks that this program for bringing up the phrenia," symptoms level of the in mental least as peculiar as the name, and there is a good deal general practitioner's knowledge of about ihe whole to disease to his level in other is too novelty conception many general general specialties and internists. and concrete a program, I have to say practitioners consulting dogmatic only I will not here in detail for the use of the that it is at all events a and that measures argue program, term instead of of some sort are in the interest "cyclothymia" manic-depressive psy¬ stringently necessary I think the of and of the mental of the chosis, although tendency usage hygiene community. certain may be advanced in favor of I trust that in the I have suc¬ logical points foregoing paragraphs a term which includes in its counsels cyclothymia, prototheme cessfully conveyed the impression that these the idea of in this dis¬ have to with nomenclature and terminol¬ periodicity, always potential nothing do ease, and in its deutetotheme the idea of affective or but with the themselves under what¬ ogy, only groups emotional disorder, a constant feature of the disease. ever name I a on they might go. recently gave talk I give below the subforms of these 'eleven great with some of the neu¬ shell shock literary examples groups of mental disease.17 These subforms are a roses in the and was a group, assured afterward by product of some American textbooks and specimens practitioner that he was now certain of what he had of classification now most in vogue. I think this long suspected, namely, that there was no such thing listing, for which 1 do not wish here to argue in as I found that his idea that there shell shock. (a) detail, certainly shows that psychiatry is on a pretty was no as to idea such thing shell shock reduced the stable basis so far as classification is concerned—pos¬ that some in had been for decades his mind that (£>) sibly as stable as many other growing specialties. neuroses because do not exist (c) their symptoms Two points are to be made concerning this sub¬ were and that "imaginary" (d) to be imaginary meant joined list. The diagnosis of these entities (or gen¬ for this man to be nonexistent. Now is or is not eric groups) under the greater groups (or orders) distinction between the and the non¬ this imaginary is not to be expected of the general practitioner, nor existent too a distinction to in the medical fine implant even of the psychiatric specialist on cursory or brief student's mind? Just as the laity is unable to dis¬ examination. Indeed, I hold that much harm has and "con¬ tinguish successfully between "hereditary" been wrought by an offhand diagnosis of "general so I a medical man unable to genital," find many paresis" when all any one could say, with lab¬ "nonexistent." really distinguish between "imaginary" and oratory tests also in hand, was that the patient had If the neuroses have no structural sign postmortem, "neurosyphilis." Many errors of this sort, both.by are the neuroses nonexistent ? But peace to the soul general practitioners and by psychiatrists (including who listened to shell of the general practitioner my ourselves), are given in detail in the shock talk! with monograph pub¬ Calmly identifying "imaginary" lished by Solomon and myself13 in 1917 on neuro he is a "nonexistent," probably very good psycho- syphilis. No, it is much better for the peace of mind therapeutist among his parochial flock. of practitioner and patient that the practitioner shall I have adverted above to one little matter of nomen¬ stop short with his group diagnosis and let the entita- on the virtues of the term clature, insisting "hypo- tive (generic) diagnosis wait on the psychiatric spe¬ phrenic" as including the entire swelling group of the cialists (one of the soundest of whom is Father of so-called feebleminded. The human advantages It is not for the purposes of "brilliant," that into Time). using the term "hypophrenic" pale insignificance is to say, premature and at all events merely lucky, of some term for beside the advantages using other diagnoses that I subjoin the genera which American the so-called dementia than the term praecox group psychiatry seems, by its textbooks, to afford. borrowed by Kraepelin to designate a group of dis¬ eases from the literature. 16. Bleuler: Schizophrenie, in Aschaffenburg's Handbuch der Psychia- which he had synthesized trie, 1911. Some I wish to write a paper called "Nondemen- 17. For more particulars, see Southard, E. E.: The Genera in Certain day Great Groups of Mental Diseases, to be published in Tr. Am. Neurol. tia. Nonpraecox." Assn.

Downloaded From: http://jama.jamanetwork.com/ by a University of Manitoba User on 06/08/2015 The second point deals not with the objects of diag¬ V. Encephalopsychoses (focal brain lesion group of mental nosis so much as with the process of diagnosis. I diseases) : have the with Roman numerals [Syphilis "] placed great groups [Feeblemindedness M] (I, Syphilopsychoses ; II, Hypophrenoses, etc.) in a [Epilepsy24] certain sequence which I take to be the practical [Alcohol, gas 2*] sequence of successive exclusion and elimination that Traumatic. Note that the traumatic neuroses, although is of the most value in the of they form a group of mental diseases, belong not present phase psychiatric here in Group V, but below in Group X, the psycho¬ No use one theory. one need this sequence if prefers neuroses. another, and the sequence will inevitably change in Infectious. The infectious group of encephalopsychoses the course of time when new facts and new tests are here listed refers to cases like brain abscess and us. meningitis in which the organism has produced local granted to And not only the sequence but also destructive effects in the brain. the list itself will inevitably alter. Not only have I Neoplastic placed the greater groups or orders of mental disease Vascular. Under this group would fall the great group in a sequence, but I have endeav¬ of arteriosclerotic dementias which, be it noted, are particular practical out from the old ored or parted age psychoses, Group VIII, also to place the smaller groups "genera" of below. mental disease in a practical diagnostic sequence under Degenerative each one who chooses to "5 greater group. Again, any VI. Somatopsychoses (the so-called symptomatic group of use the items as a list and not as a sequence is entitled mental diseases) : to do so: I would claim only that some sequence is of [Glandular feeblemindedness] practical value in diagnosis, at least for tyros. [Symptomatic epilepsy] Infectious, e. g., typhoid TABULATED SUGGESTIONS FOR GENERIC CLASSIFI¬ Exhaustive, e. g., puerperal e. CATION OF MENTAL DISEASE GROUPS Metabolic, g., cardiorenai Glandular, e. g., thyrotoxic I. Syphilopsychoses (the syphilitic mental diseases) : Pellagrous Genera : T m Less common genera : VII. Geriopsychoses (the presenile-senile group of mental General paresis Syphilitic feeblemind- diseases) : Juvemle paresis edness [Epilepsy] [Involution melancholia] Nonparetic forms : Syphilitic epilepsy [Vascular] Presenile psychosis Meningitic Tahelic psychosis I8 [Alzheimer's] Senile dementia Vascular Syphilitic paranoia [Progeria] Presbyophrenia Gummatous Atypical [Late catatonia] Senile psychoses II. Hypophrenoses feeblemindednesses, (the including gra:lcd VIII. Schizophrenoses (the dementia praecox : forms of idocy, imbecility, moronity (in the English group) nomenclature feeblemindedness proper) and subnor¬ Hebephrenia Schizophasia : Catatonia Dementia praecocissima mals) Paranoid Dementia simplex [Syphilitic10] Cyclothymojd " Encephalopathic : Paraphrenia Microcephaly, hydrocephalus, focal brain disorder IX. Cyclothymoses (the manic-depressive and cyclothymic Glandular: group of mental diseases) : Cretinism, infantilism, dysadenoidism, mongolism(?) Cyclothymic constitution Mania Hereditary : Manic-depressive"8 Mixed28 Feeblemindedness, amaurotic family idiocy Melancholia Involution-melancholia Atypical X. Psychoneuroses : [II. Epileptoses (the epileptic group) : Hysteria [Syphilitic ""] Jacksonian Neurasthenia [Feeblemindedness with Symptomatic Psychasthenia epilepsy2'] Idiopathic Alcoholic Equivalent XL Psychopathoses (the psychopathic group of mental dis¬ Traumatic Narcoleptic eases) : Encephalopathic Borderland Sense deprivation psy- Prison psychosis chosis IV. Pharmacopsychoses (the group of mental diseases due Folie à deux to and Monomania alcohol, drugs poisons) : Litigation psychosis Psychopathia sexualis [Epileptic"] Paranoia Alcoholic : Psychopathic personality A. Pseudonormal : Drunkenness, pathologic intoxication, dipsomania SUMMARY B. Peripheral—Central23 The is a in a very Delirium tremens, Korsakow's dis¬ psychiatrist specialist complicated hallucinosis, field with numerous great of diseases for his ease, pseudoparesis groups C. Central diagnostic consideration. Each of these great groups Jealousy-psychosis, paranoia(?), dementia is likely to be as complicated within itself as, for : Drug example, the group of Bright's disease or the exan- Morphin, cocain, alkaloid thems. The Poison : psychiatrist is logically opposed to the Lead, gas, mercuric chlorid, special 24. These have been classified, respectively, under syphilopsychoses, Group I; hypophrenoses, Group II; epileptoses, Group III, and phar- 18. Of course this is sharply to be distinguished from ordinary tabes macopsychoses, Group IV. dorsalis and nervous disease, and from so-called taboparesis, which by 25. The term best "somatic" is here used following a frequent neurologic the nomenclature is a subform of general paresis. plan which employs the term "soma" for the 19. feeblemindedness has been classified the body at large, as against Syphilitic under syphilo- the "encephalon" or brain. psychoses, Group I. 26. This term is 20. These have been under the adopted provisionally as against the possible term classified syphilopsychoses, Group I. because of Nascher's the term 21. These have been classified under the II. "presbyopsychoses" choice of "geriatrics" hypophrenoses, Group for his proposed branch of medicine, dealing with the diseases of old 22. These have been classified under the epileptoses, Group III. age. 23. The nomenclature of these subgenera must remain dubious. I 27. if This genus, it be such, is devised to include a practically very think most workers among the alcoholic psychoses would recognize the of cases in which the in important group schizophrenic process is precipi- value of dividing them some such triple way as above. The general tated by phenomena that resemble in has not all in I the manic-depressive psychosis, or practitioner yet at clearly mind, think, distinction which there is a definitely cyclothymic course in itself suggesting the now drawn by specialists between drunkenness and pathologic intoxi- true cyclothymoses. cation and between delirium tremens and alcoholic hallucinosis. Per- 28. These two forms are designed to in it would be well leave these the include, respectively, cases haps enough to distinctions to special- which phases of pure mania of depression follow one another, and the ists were it not for the fact that so cases in which many medicolegal points hinge depression and maniacal phenomena are commingled on the practical decision in cases that fall into the hands of the police. within the single phase.

Downloaded From: http://jama.jamanetwork.com/ by a University of Manitoba User on 06/08/2015 alienist. The latter has the function of the public would be diminished by such a process on the part of and medicolegal adviser, whereas the psychiatrist is the general practitioner would be so foolish that I a practitioner whose aim is not merely diagnostic with suspect he could not be an effective specialist ; for if respect to commitment ; his aim is diagnostic with the general practitioner could grasp the main features respect to a great number of therapeutic possibilities. that distinguish these eleven greater groups of mental The general practitioner must now advance to at diseases from one another, he would carry to the spe¬ least as much responsibility in psychiatry as he has cialist scores and hundreds of cases more than he now in pediatrics, gynecology or dermatology. The gen¬ carries. For under these circumstances, the general eral practitioner, if he is to remain of value, ought to practitioner would know how to couch a great many know more about all the specialties than each special¬ more questions. ist would be apt to know about all other specialties Meantime I find from my Boston Psychopathic than his own. Hospital practice that the general practitioners are Recent reviews of the ideas of psychiatric special¬ pretty well grounded in the first seven of the major ists show a great deal of unanimity as to the major groups of diseases listed. The general practitioner groups of mental diseases. This genuine unanimity also has certain ideas the is concerning psychoneuroses, obscured by nomenclatural divergence. At the risk but is rather apt to make somewhat obvious errors in of increasing the nomenclatural divergence, I have the field of the schizophrenias (dementia praecox) been of late proposing a pragmatic key to the group and the cyclothymias (manic-depressive group). Sun¬ of mental diseases, dividing up the groups according dry patients suffer therapeutically on account of to general and special therapeutic possibilities. I delayed diagnosis in the two latter groups and espe¬ have accordingly no etiologic or somatosystematic cially from an erroneous identification of them as suggestions to offer. My classification is purely prac¬ belonging to the group of the psychoneuroses. tical and has no relation either to obvious clinical As for the psychopathias in general, the general units from the standpoint of observation or to anat¬ practitioner need not rush in where the psychiatric omic resemblances. For example, I would contend specialists fear to tread. that a grouping of mental depressions as sometimes syphilitic, sometimes cyclothymic, sometimes sympto¬ CONCLUSIONS matic, etc., gives the practitioner no orderly means of 1. The advance of the mental hygiene movement more in making his decision in a brief space of time. Such a throws responsibilities psychiatric diagnosis classification on the ground of clinical resemblances on the general practitioner. is, in office practice, next to useless, whereas the big¬ 2. The general practitioner should bring his spe¬ ger decision as to whether the patient probably belongs cialistic knowledge of psychiatry up level with his in in one of the eleven groups as herein presented is specialistic knowledge, ophthalmology and derma¬ practically much more valuable. Then if the quest tology, for example. 3. are can be localized to two or three of the eleven groups, Alienists to be distinguished from psychiat¬ the patient's fate will be greatly benefited. rists, and forensic psychiatry ("alienistics") from Again, I feel that the classification of certain dis¬ practical psychiatry, in certain ways (Table 1). eases as organic dementias hurts the outcome for the 4. There is at present great unanimity on the part patient by delaying decision. The practitioner is of American specialists in mental disease, as indicated the of common statistical rather apt to feel satisfied with thinking that a case by adoption forms (Ameri¬ is somehow organic, whereas it may be his immediate can Medico-Psychological Association). 5. a I duty to settle once for all whether the patient is syph¬ For arriving at diagnosis of mental disease, ilitic, and then to proceed to the more careful differ¬ suggest an arbitrary order of exclusion by eleven great entiation of the possibilities in the focal brain lesion groups, into which I have thrown the accepted entities. 6. Nomenclatural are much more fre¬ group. But my attitude in general with respect to the divergences general practitioner's duties in diagnosis is that in the quent than divergences on facts. 7. The use of Bleuler's term for first it is his to determine whether the case "schizophrenia" place duty the in the mental and then to to dementia praecox and of term (in cognate use) belongs group proceed for is advo¬ answer as as available clinical "cyclothymia" manic-depressive psychosis many questions ordinary cated in the line of exactitude and the forma¬ tests can answer with to the of the ready respect place tion of and relative terms. in some one of these It is adjectives patient major groups. 8. The use of a new term for the a waste of time for the "hypophrenia" certainly general practitioner various feeblemindednesses is advocated. to the with an at all approach neurologic specialist 9. The "osis" is in advocated for complicated or longstanding case in which the serum ending general test for has not been With the the larger groups of mental diseases, parallel with the syphilis performed. use of "aceae" and "osae" for botanical of for mental tests, it is orders. multiplication opportunities 10. A also a waste of time for the not tentative list of "genera" under these orders general practitioner is given in the text. to have submitted his case to such tests before bring¬ ing the patient to the specialist. I do not mean that the general practitioner should himself perform these Baking Bread with Waste Heat.—The city council of Rey¬ tests but that he should utilize some local psychologist kjavik, Iceland, has begun the experiment of baking bread competent to perform them. in a special bakery which utilizes the waste heat from the local gas works. The result has been excellent in a And so the list, if the and through general practitioner short to a knows the main features that these time, according report of Consul B. L. Agerton at distinguish greater Copenhagen, Commerce Reports, Sept. 17, 1918, all the black of mental diseases from one he will groups another, bread which may be needed will be baked in the new bakery. be able to utilize the specialist to much greater advan¬ This is thought to be the first experiment in bread bakn^ tage. The specialist who should fear that his practice by waste heat.

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