Skae’s Classification of Mental Diseases

195 V Art. II.?

The provincial editor of the Journal of Mental Science is in high dudgeon because his teachings have been called in question, or rather, to speak more correctly, even if more metaphorically, because some of the flimsy theories of his estimable master, the late Dr Skae, which it was his object diligently to inflate, have been touched and have exploded. Skae’s classification of mental diseases has been gently pressed and has collapsed, and Dr Clouston, who has been long adver- tising it as a solid and substantial article, instead of being pensive and contrite, is indignant and aggressive. Dr Crichton Browne has given expression to various objections to that system that have long floated in the minds of all unbiassed students of insanity, and Dr Clouston has replied to his philippic in a paper that is ” sicklied o’er with the pale cast” ?not of thought, but of apparent enmity, literary enmity of the most unmistakable description. The simple truth is, that Skae’s curious construction, which he called a classification and which has been long bolstered up by a band of devoted pupils, has received a rude shock, and has suddenly toppled over and crumbled into dust. That dust, however, is now stirred by a tumult of frantic fidelity, and is raised into a cloud that obscures the vision of on-lookers and conceals for a time the extent of the destructive disintegration. It shall be ours by a whiff of criticism to blow aside that cloud, and to show that there is nothing at its core but Dr Clouston, in a very perturbed state. It shall be ours also to contend with Dr Clouston, to convince him that Skae’s system is no more, and to employ such moral force as may be necessary to appease him.

It is not an agreeable task that we have undertaken, to apply the bellows to a dialectic dust-cloud, and to grapple with an incensed adversary; but it is a needful one in the interests of that medico-psychological science which we in some degree represent. And as it is not an agreeable task, so neither is it an easy one, as there are special difficulties that attend it. It is, for instance, no easy task to grapple with Dr Clouston, not because of the strength and firmness of his intellectual grip, but because of its very weakness, together with the individual peculi- arities of his mode of warfare, of which we have learnt some- thing from watching him whilst engaged in combat. Whenever he seems to have got a hold, he instantly lets go again. Whenever he has taken up a position, he changes it. The agility with which he avoids an argument, the confused manner with which he makes an onslaught, and the shouts of victory which he emits when hopelessly worsted, are all very perplexing to his opponent. It is apparent that Dr Clouston, though endowed with much mental adroitness, does not possess those habits of perspicuous thought for which his countrymen are so often distinguished. Perhaps his philosophical has not kept pace with his medical training. At any rate he is slow to comprehend general principles, and quick to slip, whenever opportunity offers, out of the abstract into the concrete. His reasoning is often faulty, and his opinions are indistinctly set forth. Add to this that his style is at once involved and slip- shod, and it will be understood why it is somewhat difficult to maintain a discussion with him.

But beyond the difficulties enumerated as complicating any discussion with Dr Clouston, there are others that are special to that discussion that we have undertaken. In the defence of Skae’s classification, his feelings are warmly enlisted, and it is in the nature of all excited feelings to interfere with the equilibrium of intellect. Thus it is, doubtless, that he has repeatedly misunderstood the arguments to which he has volunteered to reply, and has misrepresented (unwittingly, we quite believe) the statements of his antagonist. His essay bears the traces of hot haste. Its pages have been written at a time when he had not at his very finger tip the paper which he was engaged in refuting. Thus have misreadings and misinterpretations occurred, and thus have fresh obstacles been put in the way of those who have to be critics three times removed. We shall do our best, however, under try- ing circumstances, to meet Dr Clouston along his whole line, and we can only assure him, that should we omit to notice any salient point or masked battery, he has but to call our atten- tion to the oversight, and we shall do our best to remedy it. We have to beg him to bear in mind that we are not making an original attack upon Skae’s classification (for were we doing so we should approach it from an aspect different to that which Dr Crichton Browne has chosen for his assault upon it), and are not defending any classification of mental diseases, but that we are reviewing his defence of Skae’s classification, and contrasting his essay on the subject with that of Dr Crichton Browne, with which it is in direct issue. Such a review and contrast would be skae’s classification of mental diseases. 197

unnecessary, could we feel sure that tlie two essays were read together; for then there could be no hesitation in deciding to which side victory inclined. But they are separated by an interval of time, and Dr Clouston’s has come last, and in these busy days folks are not prone to reperuse old magazines, so we think it desirable to bring the essays together to examine them side by side, and to give prominence to the triumph of the one and the defeat of the other.

At the very outset of Dr Clouston’s paper we come upon an obvious mistake, which must be corrected, as it is calculated to produce unfair impressions. ” Dr Browne,” he says on the second page of his lucubration, ” begins by a defence of Esquirol’s system,” which on referring to Dr Crichton Browne’s paper is, we discover, just what he does not do. His words are that he has ” abstained from entering upon any elaborate defence of that system,” as his purpose was not to vindicate it but to display the incompetency of its rival. He has indeed confined himself to answering four objections to it advanced by Skae, and has not travelled beyond these to express any approval of it, or to repel objections from other quarters. Dr Clouston proceeds upon the assumption that Dr Crichton Browne has put forth his whole strength in support of Esquirol’s classification?which is not really Esquirol’s after all,?and that he has given in his unqua- lified adherence to it; whereas it is obvious enough that he does not accept that classification, although he prefers it to Skae’s, and maintains that his objections to it have no. validity. The one characteristic in Esquirol’s classification which Dr Crichton Browne homologates is its adoption of the mental symptoms of insanity as the primary basis of division, but he goes with it no further than this, and indeed affords an inkling that he does not consider the partition as carried out by Esquirol satis- factory, and that having effected a primary division by mental symptoms, he would for his own part connect these with bodily symptoms and so arrive at specific differences. To his pupils it is well known that neither in his clinical work nor as a lecturer has he identified himself with the details of Esquirol’s system. It is on the point in which Dr Crichton Browne does agree with Esquirol, the adoption of the mental symptoms in insanity as the basis of primary division, that he and Dr Clouston first come into collision, and a very fundamental point it is. Skae had objected to Esquirol for adopting that basis, Dr Crichton Browne had replied to Skae, and now Dr Clouston makes an effort to reply to Dr Crichton Browne. His creed is that symptoms ought not to form a basis of classification, but he is not very fluent of reasons for the faith that is in him, and never states in exact language what basis he would substitute 198 skae’s classification of mental diseases.

for that which he desires to abolish. He seems to have some puerile anticipation that we shall yet arrive at actual patholo- gical entities ; for after repeating the rather trite observation of his opponent that we are ” still as far as ever from mounting a delusion in Canada balsam or from detecting despondency in a test tube,” he ruefully exclaims, ” The dream of so many patient workers in clinical and pathological fields is a mere chimera.” Dreams often are chimerical, but we were not aware, until we read the above, that our pathologists and clinical observers were haunted by such monstrous visions of the night. It is almost a pity to disturb such touching faith in dreams as that which Dr Clouston evinces, and which must cheer and sustain him vastly in his investigations into the morbid anatomy of the brain, but we are bound to tell him that he might just as well start on one of Cook’s Excursions in quest of El Dorado, or boil down vegetables in a search after the elixir vitce, as strain his eyes in hunting for delusion cells. He is himself the victim of a delusion in entertaining the possibility of such a discovery, and we should give much to ascertain out of what kind of notion of a psychical process such a delusion can have arisen. Why with reference to the crudest of delusions, hallucinations of the senses, Wundt, the great exponent of physiological psychology, asserts that their basis is a more energetic central impulse than that of normal fancy and of memory, which impulse reaches the peripheral regions of the senses, and so approximates to the nervous process of perception. A hallu- cination is therefore a nerve cell and fibre change, involving centre, trunk, and periphery, and travelling at the rate of one hundred and ten feet a second, and this the sanguine Superin- tendent of Morningside hopes to catch on the wing. His next step will probably be to make a section of a telegraph wire with the expectation of reading off in his microscope a message in the act of transmission.

We have no wish to attach any stigma to Dr Clouston when we say that the doctrine to which he gives countenance in encouraging such dreams is the rankest materialism, and reduces everything vital and mental to conditions from which the extraorganic is excluded. It attempts to explain pheno- mena of a higher in the terms of a lower order, to explain mind by chemistry and physics ; it makes brain solid, mind and thought the property of nerve cells. This utterly illusory con- ception is indeed more than encouraged by Dr Clouston; it is adopted by him, for he looks forward to the time when ” we shall know precisely the state of the brain cells which causes a woman to be restless, violent, and sleepless, to mistake identities, and to forget her sucking child.” Well may the most thought- skae’s classification of mental diseases. 199

ful of physiologists declare, in view of extravagances like this, that great nonsense is uttered about the modern central nerve cells ! Well may he designate a misleading artifice the selection by Courbe of phosphorus as the “principe excitant du cerveau, without which the brain of man is brutalised, with an excess of which it is goaded into madness, and from a just proportion of which the sublimest ideas and the most admirable harmony proceed.” This theory of Courbe, which chemistry has dissi- pated and which the biologist turns from with contempt, re- ferring its votaries to the bones, where they will find much more of their beloved phosphorus than in the brain, is not a whit more preposterous than Dr Clouston’s prediction that we shall before long read off the written troubles of the brain, and actually perceive a mental process. That pigs see the wind is currently believed, but that men may see mind has not hitherto been suggested. It has been reserved for a countryman of Dugald Stewart to make that prophetic announcement, which is indeed worthy of the scientist who not long ago, at a medical meeting, expressed his conviction that there is a sleep centre in the brain, a sort of stop-cock arrangement by which con- sciousness is turned off at the main. How we are to see the state of the brain cells that causes delusions and lapses of memory is not very evident, but perhaps Dr Clouston contem- plates vivisections of a more startling description than have yet been attempted. As yet the brain cells have not been brought under observation until ” after life’s fitful fever they sleep well” in chromic acid and carmine ; but we can picture to ourselves in the enlightened future a dozen microscopical phrenologists of Dr Clouston’s calibre, each with a Hartnack fastened on to a bump of a living cerebrum, and each disentangling some ” ravell’d sleeve of care.” The consummation or chimera is, however, still remote, and practically we agree with Dr Crichton Browne that we shall never accurately make out the molecular changes that correspond with mental aberrations, and that these changes can therefore furnish no direct assistance in the clas- sification of the insanise.

At the risk of being tedious, we must settle this question with Dr Clouston, because it lies, as he says, ” at the threshold of the main enquiry,” and if he trips over it there we shall be the better prepared to understand his unsteadiness and stumbling as we accompany him through the many chambers of his logic- house. Dr Crichton Browne says that we shall never make out the molecular changes that correspond with mental aberrations, and that therefore these can give no direct assistance in the classification of the insanise, and Dr Clouston characterises this as ” a mere assertion.” In order to make manifest the hollow- ness of this assertion he performs a curious feat, which he calls reversing it?as if it were a baby with a button in its throat. ” Let us see what reversing all this would bring us to. Day by day it becomes more apparent that we shall soon accurately make out the molecular changes which correspond with mental aberrations, being on the eve of mounting a delusion in Canada balsam. It is clear, therefore, that a knowledge of these changes will furnish a direct assistance in the classification of the in- sanise. Am I right in holding this position to be as good as the other, and as near truth? Neither of them are true inferences.”

Now all this is not reversing Dr Crichton Browne’s reasoning, but it is stating the contrary; but we shall not insist on that, because we hasten to apprise Dr Clouston that both the in- ferences which he pronounces false are true. If the molecular changes can never be discovered they can never be made prac- tically useful; if they are discovered they will probably be made practically useful. Both these inferences are legitimate, and the first is inevitable. But it is not to Dr Crichton Browne’s inference, but to his affirmation, that Dr Clouston means to take exception; only, unfortunately, affirmation and inference, inductive and deductive reasoning, are all one to him. What he means is that Dr Crichton Browne’s proposition is unwarrantable, and to show this he makes the counter proposition which is, he holds, more justifiable. But the difference between them is just this: that while Dr Crichton Browne’s proposition is in accordance with all human experience, Dr Clouston’s is opposed to it. Granted that a definite thought and a definite molecular action in the brain do always occur simultaneously, we possess neither the intellectual organ to pass by a process of reasoning from the one to the other, nor the sense organ to perceive the transformation of a nervous excitation into a sensation or of a sensation into a motion. The psychical and the neural process are alike beyond our ken. By the very conditions of their oc- currence they defy investigation, and even if the functionally active brain could be submitted to every kind of scientific interrogation, we should still be as far as ever from the desired knowledge. For the brain is a complex organ, the united action of which is indispensable, and any exploration of the action of one set of convolutions, or one area of cells, as ideational, emo- tional, or sensational, which did not at the same time embrace the contemporaneous changes in all convolutions and all cells would be faulty and fragmentary. Nay, more than this, for the brain is the mere crown of the nervous system, and whilst it is legitimate in a wide sense and with due caution to speak of it as the organ of the mind, and to localise in it certain mental functions, it is never to be forgotten that it isas it were dis- skae’s classification op mental diseases. 201

seminated through every organ, in elements more or less identical in structure with those of which it is itself composed, and which are in intimate functional communication with it, and that it is ” the man and not the brain that feels and thinks.” ” Even were the cerebral cells of the same importance in the psychical mechanism,” says Lewes, “as the mainspring is in the mechanism of a watch, we should still deny that sensation and thought were properties of these cells ; as we deny that the indication of time is the property of the steel spring. Mind is not a property, it is not even a simple function. It is the aggregate of the sen- sitive phenomena, and can only be interpreted through the organic condition of these phenomena : in the same way as life is not a property nor a function, but the aggregate of organic properties.”

If, then, mind is not an ultimate property of nerve cells, how foolish is it to grope amongst these cells for an explanatior of its morbid perversions. If the functional activity of these cells is not discernible, how foolish is it to seek to discover the disorder in that functional activity that corresponds with insanity. And if that disorder cannot be discerned in life, how worse than foolish is it to hope that we shall discern it after death. Will Dr Clouston now affirm that we are on the eve of mounting a delusion in Canada balsam? “Will he assert that Dr Crichton Browne drew a groundless inference when he wrote ” It is clear, therefore, that these changes (molecular brain changes) can furnish no direct assistance in the classifica- tion of the insanise”?

We have no desire to undervalue the results obtained by an enquiry into the histology of the brain in insanity, but we think with Dr Crichton Browne that these are useless for classification, inasmuch as they are degenerative results, and not efficient causes. Dr Batty Tukehas made the same remark: ” Brain lesions are, as far as I know, more the result than the cause of perverted action, even as the atrophy of muscle is dependent on non-action or hypertrophy on over action.” But supposing for the sake of argument?though the supposition is preposterous?that there is a brain lesion in every case of in- sanity, and that Dr Clouston can single it out; is he then much further, we would ask, towards his accurate pathological classifi- cation ? Let him listen then to Dr Brown-Sequard : ” Long ago it should have been found out that between the primitive cause of symptomatic manifestations (that cause being located where there is evident organic disease of the brain) and these manifestations themselves there exists a middle term, an inter- mediate element, which is the efficient or immediate though secondary cause of the symptomatic phenomena or effects. In 202 skae’s classification of mental diseases.

other words, it should have been found that the symptoms of a lesion of the brain are not immediate or direct effects of that lesion, but proceed from an unseen but perfectly discoverable alternation in parts of the cerebro-spinal centres more or less distant from the seat of the known lesion.” But supposing again that all this is practicable?that in every case of insanity there is a definite lesion, and that Dr Clouston can thread his way from that lesion to the middle term, and putting his finger upon it, say, Here is the fons et origo mali, how is all this to be done during life? We are agreed that a classification must be practical. We are agreed that Canada balsam is not applicable until after death. How are we to make the mole- cular brain changes available for classification during life ? Dr Clouston is silent. Dr Cricliton Browne’s reply is this: There is only one way in which we can approacli such changes, and that is through modifications in the outward perceptible signs of the functional activity of the organism. And as in every disease it is the rule to attach primary importance to the modifications in functional activity of that organ or set of organs, which is principally involved, and as the brain and nervous system are principally involved in all varieties of insanity, it must be to the modifications of their functional activity, that we must attach primary importance in studying and in classi- fying mental diseases. Modifications in consciousness and in action, as ascertained by comparison with healthy standards, these must be our basis of classification. We must be content to seize upon the signs and symbols of insanity, and by a thoughtful analysis and synthesis of these to distinguish as well as we may their cerebral starting-points. Therefore Esquirol was right in founding his divisions upon mental symptoms. This conclusion seems unavoidable.

The illustration given by Skae to show that Esquirol was not right but wrong in founding his divisions on the basis of mental symptoms, was drawn from fevers, and was very minutely dissected and proved a monstrosity by Dr Crichton Browne. But the demonstration thus afforded has not proved convincing to Dr Clouston who stands by bis master’s non sequitur with much obduracy. The statement was in effect that to classify the insanise by their mental symptoms is very much the same thing as if we were to classify fevers by the varieties of delirium by which they are characterised. Any schoolboy could expose the fallacy of this. Let us take the converse statement and try how that reads. To classify fevers by the pyrexia is very much the same thing as if we were to classify mental diseases by the bodily temperatures by which they are characterised. That is to say, that to classify one skae’s classification of mental diseases. 203

group of diseases by a symptom of primary importance is very much the same thing as to classify another group by a symptom of altogether secondary consequence. Fevers are bodily dis- eases, and may or may not be accompanied by mental symptoms. They are properly classified by the bodily symptoms. The insanise are mental disease, and may or may not be accom- panied by bodily symptoms. They are properly classified by the mental symptoms. Dr Clouston, however, is blind to this, and actually asserts that Skae would have been wrong in contrasting the classification of the insaniee by the mental symptoms with that of fevers by the pyrexia, because that ” would have been taking one kind of symptom in one disease to compare with a different kind in another.” How is such a frame of mind to be dealt with ? Only by varying the statement again and again, so we shall put it in yet another shape. What is the question ? (We constantly break into the Socratic method, for we find it most suitable for Dr Clouston.) The question is, how shall we classify the insanise. Shall we do so by the mental or the bodily symptoms ? By the bodily, cry Drs. Skae and Clouston ! Why so ? Because?and here is the precious little gem of ratiocination?because when you attempt to classify bodily diseases by mental symptoms you break down. Because the state of the pulse does not enable you to classify diseases of the stomach: it is in vain to hope that changes in the biliary secretion will afford you any help in differentiating the diseases of the liver.

Both Skae and his pupils have again and again condemned Esquirol and others for classifying mental diseases by their mental symptoms, but not one of them has shown what general principle that system of classification violates. The only general argument against it is that it is subjective and meta- physical, which leads us to recommend that all members of the Morningside school should in future prefix to their papers an explication of terms, as they have evidently a jargon of their own which is somewhat unintelligible. If the statements, gestures, movements, conduct of a man?and it is upon an obser- vation of these that Esquirol’s divisions are founded?are sub- jective and metaphysical, then has our education been indeed neglected. We had been under the impression that Esquirol’s system proceeded upon the objective aspect of psychology, and was only indirectly connected with the subjective aspect of the subject- We had thought that objective psychology was one of the concrete sciences, which successively decrease in scope as they increase in speciality; and we had thought that sub- jective psychology was a science too, though of an independent and unique nature: but we speak with great diffidence on such 204 skae’s classification of mental diseases.

matter, in the presence of the philosophers of Morningside? the Sensibles, we believe they call themselves?who have evidently caught a distant echo of Courbe. Perhaps the best plan will be to take refuge in Herbert Spencer, who says, “The claims of psychology to rank as a distinct science are thus not smaller, but greater than those of any other science. If its phenomena are contemplated objectively, merely as nervo-muscular adjustments by which the higher organisms from moment to moment adapt their actions to environing co-existences and sequences, its degree of speciality even then entitles it to a separate place. The moment the element of feeling or consciousness is used to interpret nervo-muscular adjustments as thus exhibited in the living beings around, objective psychology acquires an addition and quite excep- tional distinction. And it is further distinguished in being linked by this common element of consciousness, to the totally independent science of subjective psychology?the two form- ing together a double science, which as a whole is quite sui generis.”

The way in which this totally independent science of subjective psychology is spoken of by English students of insanity, and above all by the Morningside Sensibles, is very disheartening, and must humiliate us in the eyes of foreigners. Subjective states and objective states are both existents, and no one can shut his eyes to either the one or the other. Every physician’s first question, ” Where do you feel pain ?” is an appeal to self-consciousness, and an invitation to introspection ; and the very terms which an asylum physician must use daily, to wit, feelings, ideas, memories, volitions, sensations, emotions, have acquired their several meanings through self-analysis. And yet Skae and his school pretend to discard not only sub- jective, but all psychology. As we shall presently see, they will have none of it, but put it in the same category with witchcraft and mesmerism. Dr Batty Tuke says that it is psychology that has retarded the progress of ” Alienistic Medi- cine and, to clench the matter, he invokes the help of Dr. Maudsley, who has said, ” The despair of anyone writing upon mental diseases at present is, that he cannot convey just and adequate ideas of them by any care or labour of expression, so long as men will judge them by the revelations of self-con- sciousness. Such practice is not a whit less absurd than it would be to form conclusions with regard to convulsions on the basis of the recognised power of the will over voluntary muscles.” How this despair is to be converted into confidence, where ano- ther vocabulary and code for judgment are to be obtained, Dr. Maudsley has not yet disclosed. His analogous case of absurdity skae’s classification of mental diseases. 205

has not been felicitously chosen, as Dr Hughlings Jackson has shown that the true way to study convulsions is on the basis of the recognised power of the will over the voluntary muscles, and has indeed applied that principle with brilliant success. As to the way in which subjective phenomena are to be sup- planted, Dr Clouston has been more communicative than Dr. Maudsley, for repeating Dr Crichton Browne’s pregnant inquiry, ” What should we know of a neuralgia, or of a stomach-ache, but for subjective experiences?” he informs us that if a phy- sician, instead of attending to the subjective symptoms in such ailments, “looked at the teeth of his patients, ascertained if they were pregnant or nursing (and patients of both sexes are referred to, be it remarked), examined them for schirrus of the duodenum, or obstruction of the bowels, he would be in a better position to treat them.” Now, waving the objection that a physician who in an ordinary case of neuralgia or colic went through all this performance would make himself intolerable, we may just point out that all Dr Clouston’s intricate investi- gations come after diagnosis and classification, and aid in these not one iota. A patient tells you that he has intense periodic pain in the course of the fifth nerve. You cannot see, hear, touch, taste, nor smell this, and yet you say at once, neuralgia; you diagnose and classify, and you do so upon subjective symptoms. Subsequently you look for decayed teeth, or preg- nancy, or hunt up ague or other etiological relations ; and these are most important, but they come after classification, and cannot even facilitate it in any way. That must rest upon the subjective symptoms. Suppose the physician dismisses his neuralgic patient, and finding in the next patient who enters his consulting room (really afflicted with gravel) a dozen decayed teeth and pregnancy, following upon ten years’ resi- dence in the fens, diagnoses neuralgia, he would probably be laughed at; and why so ? because the subjective symptoms are not there. These, in such maladies, are all in all, and without them the somatic symptoms are as nothing. ” The etiological method of going to work,” as Dr Clouston terms it, when applied to bodily diseases, at once reveals itself to the meanest capacity as a misleading and treacherous sham, some- thing like the promoting methods of going to work prevalent on the Stock Exchange.

But we are not now interested in advocating the claims of subjective psychology to attentive consideration, and have only referred to it to contest the statement that Esquirol’s divisions of mental disease are in any way dependent upon it, as Skae and his pupils imply, not fully understanding what they say. Esquirol was never himself mad, and never affected to have 206 skae’s classification of mental diseases.

gone down into tlie depths of a madman’s mind, but he lived amongst madmen ; he conversed with them ; he watched them under varying environments, and at all hours; he tried them in numerous ways, and noted all their bodily peculiarities and changes; and, according to the outward display of their sensations, impulses, desires, emotions, sentiments, thoughts, and volitions, lie grouped them into great classes, the natural- ness of which must be apparent to even non-medical minds. It is erroneous, therefore, to describe Esquirol’s system as a metaphysical one, and the only general objection to his method is thus set aside.

But it was not in general, but in particular objections to Esquirol that Skae excelled. Unable to say on principle why Esquirol was wrong in taking symptoms for his basis, he con- sidered himself well capable to demonstrate in practice that the results of such a method must be disappointing. He brought forward three practical objections to Esquirol’s classification, which proved it, he believed, to be unsound, unsatisfactory, and uncertain. These were :?1st, That the various so-called forms merge gradually into each other; 2nd, That forms sometimes change very rapidly; and 3rd, That forms sooner or later partake of the symptoms of other forms. Under each of these heads Dr. Crichton Browne has replied to Dr Skae at great length; and as Dr Clouston has not touched upon any of them, we may con- clude that he admits the force of the reasoning directed against them, and abandons these positions. It may be taken that these objections are withdrawn. While this is satisfactory, for the positions are quite untenable, we cannot help regretting that Dr Clouston has not thought fit to reply to the comments on Skae’s method, made under these several heads. Some very telling points are made against the system to which he is wedded, under each of them; and the criticism on the case of folie circulaire is particularly instructive, as exhibiting how unequal that system is to support, the slightest strain. Instead, however, of answering these comments and parrying the thrusts directed at Skae’s classification under cover of them, Dr Clouston sets himself to another work, to expose the reckless audacity of his opponent. He has come upon a little nest of iniquity that must be harried. ” In seven successive sentences” of Dr Crichton Browne’s he has discovered ” as many statements as to the opinions and proceedings of Skae and his pupils, every one of which would be repudiated by them.” This is indeed an atrocious affair, and must be looked into. Seven violations of the ninth commandment. Seven cardinal sins in seven sentences ! The whole seven of these closely-packed transgressions are not brought to light, but skae’s classification of mental diseases. 207 five of them have been pilloried, and with reference to them ?we are in a position to decide whether they are sins after all, and are worthy of this public disgrace. The first of them consists in the statement that Skae and his pupils claim to have been the first to insist on the great truth than insanity is a disease of the brain. When and where did they do this ? asks Dr Clouston. Let us consider what might be said in reply. The allegation is that Skae and his pupils claim to have been the first to insist on (not to announce or promulgate) the great truth, that insanity is a disease of the brain, and the paragraph quoted from Dr Batty Tuke that his nosology was ” the first to keep ever before us the all-important principle that insanity is a disease of the body ” warrants that allegation, for to insist on a great truth, and to keep ever before us an all- important principle, amounts to pretty much the same thing. But many other passages might be given, setting forth the same claims and even deploring the small success that has attended the propaganda of the all-important principle. Thus Dr Tuke says, ” Insanity is not regarded by the profession at large as a somatic disease,” and ” It is not difficult to see why insanity is so far behind as to be regarded as a disease of the intellect.” He deplores ” the general non-acceptance of the pathological fact that insanity is an indication of disease of the brain.”

On the whole, judgment will be that Skae and his pupils have made the claims ascribed to them, and the first sin may come out of the pillory where, like many innocent sins before it, it has stood for truth’s sake. The second sin is like unto the first, and consists in the assertion that Skae and his pupils have protested against any attempt to apply to insanity (a disease of the brain) the same method of classification that has been applied to disease of all other organs. Nowhere have they done this, says Dr Clouston. But surely he will not dispute that they have protested against Esquirol’s method of classification, that that method has been described by Skae as a ” classification of symptoms,” or that the diseases of all other organs of the body besides the brain are and must be classified by symptoms. It follows, therefore, that they have protested against an attempt- to apply to insanity the same method of classification that has been applied to diseases of all other organs, and sin No. 2 may descend from its ” bad eminence.” Sin No. 3 consists in the statement that Skae and his pupils have pronounced Esquirol’s system unsound because it was founded on clinical observations.

Nowhere have they done this, says Dr Clouston. But surely they have again and again declared that Esquirol’s system is 208 skae’s classification of mental diseases, unsound, and is a classification of symptoms, and surely symptoms are clinical observations, and surely their own system is founded on etiology or early history, which are not clinical observations; and surely the necessary corollary of all this is that they have said that Esquirol’s system is unsound because it is founded upon clinical observations. And so it comes about that, as Peter Peebles would have said, sin No. 3 is assoilzied. Sins Nos. 4 and 5, when scrutinised, are found to be identical, or at least as like each other as the two Dromios. No. 4 consists in the statement that they give the preference in classification to the fewest and most trivial attributes; and No. 5 in the de- claration that they devote their attentions wholly to those cir- cumstances in insanity that have a minimum significance. It would take the eye that is to discover the delusion cell to make out the difference. Not being the possessors of that eye, we shall lump these sins and take them as one: the statement that they classify by minor, and not major attributes. Well, surely this is so. The things to be classi- fied, be it remembered, are mental diseases?not diseases, but mental diseases. Now, what makes them mental diseases but the mental symptoms, which are therefore the major attributes? Just as in bodily diseases the major attributes are the bodily symptoms. Surely anyone who classified bodily diseases by the mental symptoms?and in many diseases there are mental symptoms?would be said to classify by minor attributes, and surely therefore anyone classifying mental diseases by the bodily symptoms may be fairly said to proceed in the same manner. Sins 4 and 5 may go Scot free.

From discharging the august duties of public censor Dr. Clouston returns to Esquirol, for whom he has reserved a coup de grace with which he is to be finally dismissed into oblivion. He has a test that will settle the virtues or shortcomings of his system. ” Does Dr Browne deny that general paralysis, with its alternations of mania, melancholia and dementia, is a true cerebro-mental disease, a distinct clinical symptomatological and pathological reality ? If he admits this, how does he classify it among Esquirol’s divisions?” How Dr Crichton Browne would deport himself, what he would say or do under this scathing ordeal, we can only surmise. As for ourselves, if thus cross-examined, we should reply that we at once admit that general paralysis is a distinct disease, or, as Dr Clouston has it, ” a distinct clinical symptomatological and pathological reality,” but that we cannot forget that we do not owe any of our knowledge of this disease, which was first differentiated by Calmeil chiefly by its mental symptoms?to Dr Skae or skae’s classification of mental diseases, 209 his school, although they are in the habit of referring to it, as if it were a little discovery of their own. We should then remind Dr Clouston that we have not pinned our faith to Esquirol’s robes, and are not bound to find a place for general paralysis under his divisions, and we should also remind him that Esquirol himself did what he asks us to do, and lectured upon general paralysis as Monomanie Ambitieuse and as Folie des Grandeurs dans ses rapports avec la Paralysie Generate. We should add, however, for Dr Clouston’s complete satisfaction, that for ourselves we should class general paralysis among states of mental weakness as a progressive dementia with general paralysis. The alternations of mania and melancholia have not been properly sifted when they have been so designated, and Salomon hits on the essence of the malady when he says, ” In the very commencement of the cerebral morbid process the mind appears injured in the conditions fundamentally necessary to the normal discharge of its functions; it is diseased in its very roots.”

It is time now to turn from Dr Skae’s objections to Es- quirol’s system, to Dr Crichton Browne’s objections to Skae’s, which Dr Clouston flatters himself he has put through a very small sieve. These are really ten in number, six having reference to the general principles of the system, and four to some of its details; but Dr Clouston has been able to make out only eight, and has not understood that they are marshalled in two divisions. And, more than this, he mis- states the first objection, which is, he says, that the system has no principle of construction, no bottom: the fact being that the objection urges that, notwithstanding Dr Clouston’s attempt to deprive the system of any principle of construction or bottom, it has one of the worst description, an etiological principle of construction or bottom. In introducing the system in its ma- tured shape to the Eoyal College of Physicians of Edinburgh, Dr Clouston laid it down with emphasis, that the principle at the bottom of Skae’s system is the ” exclusion of everything mental or psychical connected with insanityThat, in his view, was its archetypal idea, its crowning glory. But now it appears that after reflection, with admirable self-abnegation, Dr Clouston is ” not much concerned to defend his own defini- tion.” We dare say not. We quite believe that he would much rather abandon it; but we object to desertion, and must insist upon Dr Clouston standing by his bantling?that is evidently the child of long cogitation and agonising throes. ” I have ventured to define Skae’s system as exclusively somatic.” ” The principle at the bottom of Skae’s classification is the exclusion of everything mental or psychical connected with insanity 210 skae’s classification of mental diseases.

ana the italics are his. ” This is by far the most important principle that ever was adopted in this department of medicine.” These passages, and others that might he quoted, embody what is no mere inadvertent expression of Dr Clouston’s, but his deli- berate judgment on the system of which he is the chief apostle, and they reveal, better than anything that we can say, his quali- fication for the work to which he has dedicated his powers. And other members of the Morningside school concur with him as to the propriety of ignoring mental symptoms. For we have Dr. Batty Tuke expressing his ” firm conviction that the only means of establishing a definite classification of so-called mental diseases is to adopt pathology as the fundamental principle without any regard to mental symptoms.” Conceive a physi- cian talking thus: ” I define my classification of renal diseases as exclusively hepatic. The principle at the bottom of my classification is the exclusion of everything urinary, connected with kidney disease.” That is parallel to what Dr Clouston says, and we should prefer not to express our opinion of any- one who could give utterance to such incoherency. Dr Orichton Browne’s statement that Dr Clouston’s attempt at definition? which is defining a thing by what it is not?is a magnificent recluctio ad abswrdum of Skae’s system, is quite correct, and Dr Clouston’s clumsy efforts to shake off the charge are more amusing than successful. We are sorry to ruffle his self-com- placency, but it would, we- must assure him, have been a magnificent reductio ad absurdum still, had any one in pleading for the natural system of classification of plants, defined it as the exclusion of everything connected with the number of the stamens and pistils. The definition, or rather no definition, would have been palpably erroneous, and we trust it will never be known to Professor Balfour that any pupil of his suggested it. But even this discreditable suggestion falls short of the absurdity to which Dr Clouston has committed himself. In the classification of plants, their characters form the basis of clas- sification, and the exclusion of the pistils and stamens from classificatory consideration would only amount to the sacrifice of one set of characters, leaving many other sets still available. But in mental diseases, as we maintain, the mental symptoms form the basis of classification, and the exclusion of these symptoms from classificatory considerations is tantamount to the abandonment of the whole basis. In the classifica- tion of mental diseases, the case parallel to that which Dr. Clouston incontinently supposes in the classification of plants would be the exclusion of one set of mental symptoms, e.g., those connected with the propensities or emotions, and in the classification of plants the case parallel to that which skae’s classification of mental diseases. 211 Dr Clouston recommends in the classification of mental dis- eases would be the exclusion of everything connected with the root, stem, leaves, flowers, fruit, and seed.

Dr Clouston himself acknowledges that the definition which we have just been examining was not Skae’s, but his; and he practically gives it up, and allows Skae to speak for himself. Dr Crichton Browne’s interpretation of Skae is that his principle was mainly an etiological one, although not altogether so ; and here we must notice the curious manner in which opinions are foisted upon Dr Crichton Browne, in order that they may be controverted and their putative parent discredited. It is represented that he has regarded Skae’s classification as having a purely etiological basis. ” Thus, Dr Browne being led away with supposing that Skae’s system was a purely etiological one throughout.” ” It is a pity that Dr Crichton Browne had stuck to his preconceived idea that Skae’s system is a purely ‘etiological one.’” ” Now both of these statements depend for their truth and force on the theory that Skae’s system was entirely an etiological one.” By these and other phrases it is sought to create the im- pression that Dr Crichton Browne has done flagrant injustice to Skae’s system and has trifled with its fundamental principle, while all the time the injustice is done to Dr Crichton Browne, who reproduces Skae’s own words, and studiously avoids going beyond what they warrant. Again and again his words are, ” This system is mainly an etiological one.” Not once does he hint that it is solely so. Nay, one of his substantiated objections to the system?an objection that Dr Clouston, while professing to deal exhaustively with his critique, by a strange coincidence never alludes to?is that no one plan of construction is adhered to in it, but that it has five other bases of classification as well as the etiological one. He accuses Skae of inconsistency in shifting his ground so often, and in choosing other besides causal conditions as his guides, and intimates that in no other depart- ment of knowledge except medical psychology would a classifi- cation with so many distinct bases have received a moment’s toleration. It would be prudent, perhaps, in Dr Clouston to explain how he came to impute to his opponent the statement that Skae’s system is an etiological one throughout. That Skae’s system is mainly an etiological one cannot be gainsaid. He has himself so described it, and Dr Clouston’s version of its genesis is as follows: ” Any strong characteristic, provided only it was a bodily one, relating to symptoms or pathology, but above all a cause, was seized on and made to do duty in naming some variety of insanity.” Dr Batty Tuke, after mildly chiding Skae for making etiology and not pathology his basis, drifts into the same channel: ” If, however, we (mis- 212 skae’s classification of mental diseases. called) ” psychologists ” (for once we are at one with Dr Tuke) ” are able to refer them ” (the varieties of insanity) ” to certain common causes, and classify them accordingly, we shall be in the prond position of claiming for onr own department a higher stand-point of nosology than can be asserted for any other branch of medicine”?that higher stand-point being the pinnacle of folly. Seeing, then, that Skae’s system is mainly an etiological one, Dr Crichton Browne was right in examining into the stability of its principle?that is to say, etiological foundation? and most people will think that he was right also in concluding that there is no stability about it. Causes are far too recondite, obscure, and indefinite to serve as a basis for classification. ” Alas for our chains or chainlets of causes and effects, which we so assiduously track through certain hand-breadths of years and square miles, when the whole is a broad deep immensity, and each atom is chained and complected with all!” How, out of such a complected immensity, are we to fix upon any one cause as the starting-point of a case of insanity ? In almost every case of insanity numerous causes, near and remote, predisposing and exciting, moral and physical, have been at work. By what scientific process are we to give the preference to any one of these, and make it the basis of nomenclature, when we can have no means of gauging what share was taken by each in the pro- duction of the result that is before us? “The fern,” writes Dr Bucknill in a recent letter to Dr Clouston, and we trust he will ponder it well, ” is evolved through countless acts of causa- tion which cannot be estimated, and there is no one act of which the most advanced biologist can say, ‘ This is the cause.’” A disease is not less far-fetched than a fern.

In no department of medicine save that which is concerned with mental disease, has etiology been taken as a basis of classifi- cation as Dr Batty Tuke is aware when he says, ” It may be objected that there is no other disease the varieties of which are based on the causating influences.” (rood reasons should therefore be given for the adoption of so unusual a course, but not a word have Skae or his pupils to say about the broad principles that guided them to their daring experiment. Perhaps we can suggest how it was that Dr Skae contracted his etiological notions. He had read the ” Traite des Maladies Mentales ” of Morel, published in 1860, and he had been much struck by the breadth, ingenuity, and learning of that great work, which has exercised an unmistakable influence over his subsequent writings. It is not within onr present purpose to trace out that influence, or to sum up the number of Morel’s ideas that Skae has appropriated ; but of this we are sure, that anyone who reads the introduction to Morel’s Treatise, and the 3rd, 4th, skae’s classification of mental diseases. 213 5th, 6th and 8th chapters of the first book, the 3rd chapter of the second book, and the whole of the fourth book, will not afterwards entertain a very high opinion of Skae’s originality. There we have, his etiological system. ” J’ai formule la loi d’une rela- tion intime, necessaire entre la forme de Valienation et la nature de la cause L’etude de ces causes, leur co- ordination, la description des phenomenes pathologiques qu’elles determinent dans les fonctions du systeme nerveux, nous permet- tent d’etablir plusieurs categories de malades alienes, et nous donnent immediatement l’economie de la classification nouvelle que j’ai adoptee.” There we have the retention of the old names to designate symptoms. ” On le voit done, je ne rejette ni la manie, ni la melancolie, ni les divers perversions des sentiments; mais je n’en fais pas les elements de ma classification.” There we have all the arguments used by Skae against Esquirol’s sym- ptomaticological classification employed by Morel against the same bete noire. “L’enchainement et la dependance reciproque des phenomenes nerveux dans la folie depuis la periode initiale jusqu’a la periode de determinaison, la succession plus ou moins reguliere de ces phenomenes selon les differentes varietes de la folie, l’alternance entre les symptomes, leurs intermittences, leurs remissions, ne peuvent se separer des transformations que subit le delire des alienes Esquirol, qui lui-meme a donne l’exemple de cette classification dans sa creation de la monomanie comme genre et des diverses monomanies comme varietes, nous avait deja appris que les anciens, apres avoir donne pour caractere de la melancholie la tristesse et la crainte, furent forces de ranger parmi les melancholies quelques delires partiels entretenus par une violente exaltation de l’imagination ou par des passions vives et gaies. Lorry, qui a si bien decrit la melancholie, ajoute Esquirol, quoique sa definition consacre l’opinion des anciens, admet une variete de melancolie com- pliquee de manie, laquelle a pour signe le delire partiel avec exaltation de l’imagination, avec une passion excitante. Rush, le medecin Anglais, divise la melancolie en melancolie triste qu’il appelle tristomanie, et en melancolie gaie, a laquelle il donne le nom cVamenomanie, et constate ainsi, dit Esquirol, les resultats d’une observation que chacun pent faire. Mais quelle confusion une pareille maniere de classer les phenomenes ne doit-elle pas jeter dans l’esprit de ceux qui veulent etudier l’alienation dans sa nature intime, dans sa marche, son developpement et sa terminaison, comme maladie rentrant dans le cadre nosologique des affections ordinaires!” There we have in connection with these arguments cases of folie circulaire, which closely resemble that quoted by Skae, “Ainsi un aliene passe trois mois dans la hypermanie, les trois 214 skae’s classification of mental diseases.

mois suivant dans la manie; enfin, quatre mois, plus on moins, dans la demence, tantot d’une maniere irreguliere.” Then we have, ” La folie causee par la masturbation, la folie dans ses rapports avec la grossesse, dans ses rapports avec 1’accouchement, la folie pendant la lactation, la folie liereditaire, la folie hyste- rique, l’erotomanie, la nymphomanie, le satyriasis, le rheuma- tisme complique de delire, delirium tremens, la dipsomanie, l’alcoolisme chronique, la folie epileptique, la folie hypochon- drique, la paralysie generale, delire systematique pendant la periode de convalescence de la fievre typhoide, l’alienation d’age critique, l’alienation de la menstruation, la folie morale, la folie idiopatliique, la folie suivant le marriage.” There we have, in short, almost all Skae’s forms, carefully delineated and indeed filled in, in a manner much more com- plete than he attempted, and there we have certainly the germs of all of them. We do not mean to say that Skae’s classification and Morel’s are identical; far from it. Although Skae has copied certain portions of Morel’s classification, he has varied his own arrangements very considerably. But what we do mean to say is, that Skae has adopted Morel’s principles, has derived a large majority of his forms from him, and has availed himself of his labours to an extent that demanded far ampler acknowledgment than he has thought fit to offer. We have no vestige of originality in Skae’s classification. If the genius of Morel failed to secure approbation for an etiological system, it is not to be expected that the mediocrity of Morningside will attain that result. And that the genius of Morel did so fail, no one will doubt who peruses a brilliant article, in which its shortcomings are shown forth with an ability now rare in medico-psychological literature, which was published in the ” Journal of Mental Science,” in July 1861. An etiological system is, and must be, radically defective, because we can rarely single out one strand from the plexus of causes as that upon which the insanity really depends; because one cause may produce many different varieties of mental aberration ; because in a certain number of cases of insanity no cause can be found; and because our whole knowledge of the causes of insanity is founded upon evidence which is seldom trustworthy and often wilfully false. Probability as to causes is all we can arrive at. Certainty as to the nature of disease is what we must aim at. And here once more we have the distressing conviction forced upon us, that Dr Clouston does not attach the ordinary every-day meaning to the language he employs. For the word cause he must have a meaning of his own, as he asks, ” What is the morbid anatomy of a disease but a branch of its causa- tion?” Now, without discussing the conjunctive nexus, we may say that we had always hitherto believed that a cause was skae’s classification of mental diseases. *215

necessarily antecedent to its effects, so that it is rather stagger- ing to be told that a consequent may be the cause of that of which it is the effect, and that constant succession may go either way, backwards or forwards. This theory, which never occurred to Hume, which is not founded upon the in variableness of nature, is like the kindred proposition that two and two make five, well calculated to necessite a revision of the universe when once it has been fairly established. But until such time we shall refuse to entertain it, and shall stick to our old prejudices, viz., that a cause must precede an effect, and that morbid changes in tissues or viscera are the consequences, and not the causes, of disease. We shall even decline to assent to Dr Clouston’s more moderate suggestion that causes, could they be accurately dis- covered, would be the best guides to the grouping of diseases, for we cannot forget that an antecedent is itself a group of causes as a consequent is a group of facts, and that to fix upon one integer in a sum of causes to the neglect of others is un- philosopliical and dangerous. Henry I. died of eating lampreys. What was the real cause of his death ? The previous condition of his system that made the lampreys disagree with him, or the vomiting that they brought on, or the inflammation of the stomach that the vomiting set up, or the decayed state of the lampreys, or the hot weather that caused the lampreys to decay, or so on to all infinity ? Dr Clouston’s idea is that causes are a simple chain, and that it is an easy matter to count up the links. The fact is that they are an ever radiating and expanding labyrinth, and the trunk of a tree has not more radicles than a disease has causes. Who shall trace the one back to its spon- gioles or the other to it primitive filaments ? Who shall say of a root or rootlet, this made the trunk, or of a cause or causelet, this made the disease ?

When he speaks of ” real causes,” ” true causes,” of ” the cause which has the closest and most real relation to the disease,” Dr Clouston probably means what is popularly under- stood as the disease itself?that is to say, that disordered function or changed structure upon which the symptoms im- mediately depend. But where is the line to be drawn between the true cause and the symptoms ? Instability of certain territories of nerve tissue in this view is the true cause of epilepsy, but the instability is the epilepsy, and without it the epilepsy would not exist. Remove the instability and the epilepsy is no more, remove any other cause setting up the instability, such as a worm in the intestine, and the epilepsy is not necessarily abolished. Then what is this instability but an inference from a group of symptoms? The actual deviation from health, the abnormal performance of those processes which constitute life in an organ or in the organism, is the disease and 216 skae’s classification of mental diseases.

not its true cause ; and even if we could get at this with cer- tainty during life, it does not follow that it would form any better basis of classification than the symptoms. Inflammation is a term founded upon a grouping and succession of symptoms, that has a well recognised meaning, but in it what might be called the true cause includes a number of true causes, such as changes in the blood vessels and circulation, exudation of liquor sanguinis and migration of the white corpuscles, and alterations in the nutrition of the tissues, which have a successive causal connexion but out of which no one can be properly selected as pre-eminent.

What Dr Clouston says about real causes, and pathological appearances, as elements in Skae’s classification, is like the exclusion of the mental symptoms, an afterthought to patch up defects and reconcile the critics. It is not to be found in Skae’s writings, where, moreover, abundant evidence exists that he was not particular in selecting only proximate causes for the bases of his groups, but seized upon conditions of various degrees of remoteness. Malaria is not a proximate cause, nor is adolescence, nor masturbation, nor hysteria, nor connubialism. What Skae does speak of in addition to etiology, or rather as an amplification of it, as the groundwork of his system is the natural history of the disease. But the natural history was after all little more than the etiology, for he gives us an insight into his conception of it. ” What we are solicitous to know is the natural history of the disease before us and its cause. Is it a congenital disease? Is it one associated with epilepsy, caused by masturbation, by parturition, or protracted lactation, or some other debilitating cause, or by hard drinking ? Is it one connected with phthisis, with the critical period, or with the atheromatous vessels of the senile dement ?” His pupils have, however, endeavoured to give a much more liberal inter- pretation to the phrase natural history. Dr Clouston would like to make it include causes, symptoms marshalled in order of occurrence, sequence, course and duration, and pathological appearances ; and this is all very well on paper, but how will it avail him or those who think with him in the wards ? It is at the outset of a case of lunacy, when it is first brought under the observation of the physician, that classification is of most moment. He must then classify it; true, his classification may be provisional and subject to correction, but the constitution of his mind obliges him to give a name to the ailment. And the name is of much more consequence than Dr Clouston realises. Naming is really diagnosis, and upon diagnosis, prognosis and treatment depend, and also perchance individual liberty, and the fortunes of a family. Now, at the outset of a case how much of the natural history of a case is before the physician ? skae’s classification of mental diseases. 217

Clearly not the progress of the case, for that he is expected to modify by treatment ; clearly not its issue, for that is in the womb of the future ; clearly not the morbid anatomy, for that too is undisclosed. All that is before him is as much of the etiology as can be ascertained, and the early symptoms. But the members of the Morningside School can take no cognisance of mental symptoms?those they have for ever forsworn?so that all they can have to form an opinion on is the etiology and the early bodily symptoms. But there are many cases of insanity in which there is no etiology, as every asylum report bears witness, and there are many in which there are no bodily symptoms, so the basis of Skae’s classification is sometimes reduced to the dimensions of a mathematical point. How the believers in that classification proceed under such circumstances we cannot profess to know. We were consulted lately by a strong ruddy typically healthy man, aged forty, who had never had a day’s illness in his life, and the one pathological spot in whose family history was that a maternal uncle was epileptic. His habits had been temperate and regular, he had been success- ful in business, and had no trouble on his mind. One afternoon, when walking in the street, he felt restless and excited, and went home, where for a couple of hours he could not sit still, but paced about talking very fast and seeming to see things more clearly than he had ever done before. At the end of the two hours he became tranquil and slept; but since that attack, which happened a month before he sought our advice, he had been haunted from time to time by suicidal and homicidal promptings.

Now strikeout the mental symptoms in this case, and what re- mains of natural history. A healthy man with an epileptic uncle. If Skae’s system is to be a mere post mortem exercise, if it is only to facilitate the labelling of specimens, then natural his- tory will serve its turn ; but if it is to be clinically useful it will require something more than the natural history v^inus the mental symptoms, that something being these very despised mental symptoms, upon which a considerable number of forms?in the grand etiological and natural history collection?are founded. So vital is this natural history question that we shall allow Dr Clouston to express his views fully on the subject:? ” The botanist’s idea, viz., the analytical process of separa- ting the characteristics of the plant into those of the class, and those of the class into those of the order, and those of the order into those of the genus, &c.,” was not Skae’s idea, and is not the method on which a clinical physician works. ” His,” the clinical physician’s method, ” must be a synthetic process. He must first hear and mark the individual symptoms of a disease; a disease, I find myself saying, as if it were an entity like a 218 skae’s classification of mental diseases. plant. It is, of course, no sncli thing, although Dr Browne talks as if it were. A disease is merely in nine cases out of ten a creation built up by the physician out of individual symptoms, related by the patient, out of the phenomena perceived by himself during life and the appearances noticed after death. Causes of all kinds must come in, symptoms must be marshalled in order of occurrence, sequences, course, and duration ; patho- logical appearances must be correlated with all these, and then the physician with the generalising faculty constructs his fabric and calls it a disease.” We have given this extract be- cause we are desirous that our readers should have an oppor- tunity of judging of Dr Clouston’s style for themselves, and should not imagine that we are too uncompromising in our strictures on him, when we tell him as we do now that the paragraph extracted is a mass of clotted nonsense. We have applied to it the analytic and synthetic process, with the nature of which Dr Clouston is evidently so familiar, and we should give him the benefit of the resulting decomposition and reconstruction. In the first place, the paragraph contains two distinct misrepresentations of Dr Crichton Browne’s views. It represents him as assuming that Dr Skae’s idea was the botanist’s, whereas he explicitly expresses his belief that Skae went astray from that idea, and so lost a noble opportunity; and it represents him as talking of disease as if it were an entity like a plant, whereas Dr Crichton Browne is careful to guard himself against any such misapprehension, and charges Skae’s school with the very misconception which is now thrown back at him. His words are, ” Skae repeatedly betrays the fact that he regards his forms as specific entities, and not as mere departures from health,” a statement that is borne out by Dr. Batty Tuke, who writes, ” In fact he (i.e. Skae) claims for each of his natural orders all the attributes of a pathological entity.”

Indisputably Dr Crichton Browne’s view is that a disease is a departure from health. In the second place Dr Clouston has not grasped the botanist’s idea and misunderstands both ana- lysis and synthesis. This gentleman, who sets himself up to tell us what the clinical physician’s method ought to be, has derived his notion of analysis from his lessons in practical chemistry, and that of synthesis from the mixing of a plum- pudding. We do not expect him to follow us when we tell him, but we must go through the form all the same, that analysis and synthesis are only two necessary parts of one method?that an analysis without a subsequent synthesis is incomplete, and that a synthesis without a previous analysis is baseless. It is only by the combination of these two pro- cedures that we can ever attain to any comprehension of the infinitude and complexity of nature. The botanist and the skae’s classification of mental diseases. 219 physician both adopt what is substantially the same procedure, although Dr Clouston represents it as diametrically different. The one, when examining a plant, isolates it from its surround- ings, considers its size and shape, fixes his attention on root, stem, leaves, flowers, and fruit successively, and one by one takes in their form, colour, and arrangement, and one by one contrasts them with the like parts of other plants, and then reverses the process, reconstructs the plant, views the parts in relation to each other, and to the whole of which they are con- stituents, rises step by step, generalising the qualities in which they coincide with others, until an induction is complete. The other, when examining a patient, isolates or selects the indica- tions of disordered from those of healthy function, considers the character of those indications, fixes his attention successively on each of them, contrasts them minutely with similar indications seen in other patients and with several known standards, then reverses the process, combines the symptoms, generalises them, and forms an induction. In the third place, a disease is not in nine cases out of ten a creation of the physician and a fabric of his building up. ‘ It exists not in the mind of the physician, but in the body of the patient, and we shall pray to be preserved from Dr Clouston, physician, with ” the generalising faculty,” if it is his practice to treat his own creation and not our suffer- ings, particularly as this creation requires for its completion the appearances noticed after death. Until we read this para- graph and learned that ” in nine cases out of ten ” a disease is merely a creation built up of symptoms related, phenomena perceived, and the appearances noticed after death, we had no idea that the mortality in Dr Clouston’s practice was so con- siderable. For our own part, in more than nine cases out of ten we have been able to create the disease if recognising, naming, and classifying the morbid process is what is meant, without any assistance from post mortem appearances. The mode in which Dr Clouston speaks of a disease as a structure, a fabric, and a creation of the physician, reminds us of one of the answers returned recently at a physiological examination at South Kensington. The question was, ” What is the respiration, and how is it brought about?” And the brief and decisive reply of one of the candidates, haunted perhaps by some tradition of the lying-in room was : ” The respiration is taking in air, and is brought about by doctors.” Dr Clouston thinks that disease is a fabric which is built up by doctors.

There is one characteristic of the Morningside School as represented by Dr Clouston to which we must here allude, and that is their narrowness. They think that no good thing is to be found out of their own little coterie. They think ” the rustic cackle of their bourg the murmur of 220 skae’s classification of mental diseases.

the world.” Skae is to them the prophet of a new dispen- sation ; beyond him there is no wisdom. The Morningside bantlings are to be the parents of a new race of psychologists, who are to replenish the earth with judgment and truth, and whoso looks past this interesting brood is merely gazing into ” the dark portals of metaphysics.” From this it comes about that Skae’s progeny concentrate what of vision is given to them upon themselves and upon each other. Self-absorption and mutual admiration?they are for ever patting each other on the back?swallow them up and shut out true culture, for they care not to acquaint themselves with the labours of alienists anterior to the coming of their own peculiar teacher. Authority before him there was none. Until Skae published his classification darkness was upon the face of the deep of lunacy. He struck the sparks whence that illumination in which we now rejoice. For Skae’s pupils the growth of know- ledge is not a regulated extension sore let and hindered by the stupidity of those who profess to promote it, but a re- volutionary expansion sudden and marvellous, owing nothing to tradition or the accumulation of ages. This miserable phase of modern sciolism in which they stand confessed explains some errors into which they fall which would otherwise be quite inexplicable. It explains, for instance, Dr Clouston’s strange blunder in accusing Dr Crichton Browne of having borrowed the names of hysterical mania and senile de- mentia from Dr Skae. Who, he demands, assigned hysterical mania its name but Dr Skae ? Senile dementia, he affirms, is a variety formed on Skae’s principles. Why, both these forms of insanity were recognised and named before Skae was born into asylum life; and had Dr Clouston looked into any standard work on insanity, he would have discovered this. Esquirol described Demence Senile, and La Folie complique avec Hysterie, and Forbes Winslow, Coupland, Grriesinger, and a dozen others that might be named, have employed these titles, and exhibited as correct an acquaintance as Skae possessed with the pathological conditions which they represent. In discussing the soundness of the main foundation of Skae’s classification, we have disposed of the question as to its practical utility. If the principal foundation is insecure, not much confidence can be reposed in the superstructure. To illustrate the inherent practical weakness of an etiological system Dr Crichton Browne enumerated the etiological con- ditions of six cases of insanity, two being adduced to show the frequent impracticability of getting at any causes, and four to show the number of causes, any one of which would be a group-basis to Skae, that often play a part in the evolu- skae’s classification of mental diseases. 221 tion of one case. Dr Clouston has wasted a vast amount of energy on these cases, and has conceded exactly what Dr. Crichton Browne wanted after all. Out of a bundle of causes in each case he selects one in the most arbitrary manner, at his own sweet pleasure, not that which is the closest to the disease, but just that which fits in best with his own views. We could have no better criterion of the practical value of Skae’s system than its success as applied by himself. We shall therefore follow him in his full practical exposition of one of his forms, and we shall then have the satisfaction of knowing that his system has been treated with no unfairness, but that its prac- tical merits have been shown forth in the best possible manner. The book opens at post-connubial insanity, a form of mental disease?if it be a form?that Skae was the first in this country to recognise and name. What has he to say about it, and what sort of cases are they that he arranges under it ? All that he has to say about it is ” that it is connected with the sexual organs, or more correctly speaking of (sic) the sexual orgasm,” a statement that might induce us to regard certain problems that a great mathematician solved during coition as speci- mens of post-connubial insanity, because they were connected with the sexual orgasm. Positively, that is the only generalised statement that Skae has to make about this particular disease.

After making it he at once wanders off, in his usual discursive style, into a touch-and-go survey of cases interspersed with a few irrelevant anecdotical remarks that remind one of a show- man exhibiting a collection of waxworks, more than of a physi- cian bestowing the fruits of his experience, and unfolding with scrupulous care, and large sweep of intellect, the great schema that it has been his life’s labour to prepare. He never rises to the height of his great argument, or apprehends the truth that he is addressing men of full-grown and trained faculties who demand strong nourishment of him who would purvey for them, and will not be put off with scraps of fanciful con- fectionery. He never threshes and winnows from his cases their grains of real worth, that he may elaborate these into the bread of knowledge for the pinched and starved disciples of Esquirol, whom he has promised to feed, but he gathers up a bundle of cases, twists them together, straw, chaff, and all, and handing the wisp to the hungry throng, says with a grace and bonhommie that deprive even a disappointed appetite of its sting, Gentlemen be so good as to help yourselves! Now let us analyse the wisp of cases that is to satisfy the natural craving for knowledge about post-connubial insanity, and that takes the place of a reasoned comprehensive illustrated description of that disease. Let us see what sort of cases are included under post-connubial insanity, so that perchance we may be able to form for ourselves some general systematised conception of the disease that may dwell with us, and be of practical service in dealing with cases that may come before us hereafter. The first cases mentioned are some in which ” the first night of connubial felicity was followed in the male by attacks of congestion amounting to something like congestive apoplexy, although of transient duration, or resembling the epileptiform congestive attacks of general paralysis.” We begin to see a glimmering of light. Unconsciousness, or partial coma, dimin- ished sensibility, clonic spasms, raised temperature, livid features, rapid pulse, laboured breathing following upon coition, and all of a transient type?these are the symptoms of post- connubial insanity. We are reassured there is something in Skae’s system after all! But our eye rests on the next sen- tence, and confusion worse confounded overtakes us. ” More often,” adds Skae, ” the symptoms of post-connubial insanity are those of acute dementia.” Let us try again. Mental torpor, enfeebled attention, defective memory, palsied will? blunted senses,. sluggish movement, partial catalepsy, vacant expression, cold extremities, shallow breathing, feeble pulse, lowered temperature, occurring in a young person immediately after marriage may then be taken as the symptoms of this disease. But how do these symptoms correspond with those previously enumerated ? Well may we feel bewildered. Faith, however, in Skae’s judgment must make us misdoubt our own penetration, and encourage us to an effort to recover our bear- ings. We shall suppose that there are two great types of post- connubial insanity, differentiated from each other in their out- ward manifestations, but linked together in their common origin, in a state of cerebral exhaustion, following upon unaccustomed sexual indulgence, combined with emotional disturbance. Ah! no such easy outlet is permitted to us from the slough of rational despond. As we are just struggling on to terra firma, Skae pushes us back once more into the clogging depths : ” In females,” he proceeds, ” the symptoms are better marked and more peculiar.” And then, of course, he launches into a case, the symptoms of which may be thus summarised: mo- roseness, remorse for having married, repugnance to her hus- band, following upon a suitable match. No bodily symptoms, mark! to characterise this case; nothing but the contemned mental symptoms are given, and these are the symptoms of simple melancholia. But in what way do these symptoms re- semble those of acute dementia, or of an attack of congestive apoplexy ? ” Oh, but,” it may be observed, ” we are now deal- ing with post-connubial insanity in the female, and that must, skae’s classification of mental diseases. 223 of course, differ from the same disease in the male.” Admitted.

We are fully alive to the fact that sex implies a group of differences between man and woman which extends to all mental disorders, but we are not aware that any sound standard of comparison between masculine and feminine human nature would warrant such a vast sexual divergence as is here assumed to characterise the two types of one and the same disease. Glance at the differences between general paralysis in the male and general paralysis in the female, and say whether they create such a gap as that which separates congestive apoplexy and simple melancholia. But the sexual explanation will not answer the purpose here, for after the case of simple melancholia Skae sketches, with unusual precision of touch, what he calls a typical case of connubial insanity in the female, that is just one of acute dementia as often seen in the male. Another case also he gives of post-connubial insanity in a woman, and that plunges us in worse despair than ever, and further complicates the problem : for it is a case neither of congestive apoplexy, simple melancholia, nor acute dementia, but of acute melancholia. A young lady, immediately after the consummation of a very proper and approved good marriage, became intensely melan- choly and suicidal. She walked up and down night and day for three months, wringing her hands, and with a face full of wretchedness, repeating the words unceasingly, ” Oh, misery, misery ! ” She was fed by force, attempted suicide in a variety of ways, and ultimately succeeded in hanging herself. We could almost echo that unhappy lady’s sentiments, and cry, oh misery, misery! for post-connubialism is a trial to us, as it was to her, and the more we try to understand it the thicker do perplexities accumulate upon us. We are, perhaps, laying ourselves open to the witticisms of facetious critics but in sheer helplessness we must ask in what feature does this case resemble those that have preceded it, as instances of post-connubial insanity. And the only reply that seems pos- sible is, that it resembles them just as much as it does the next post-connubial case that is quoted, which is one of gene- ral paralysis. Incredible as it may seem, this is yet strictly correct. A gentleman, whose wooing by proxy is described with gusto, immediately after his marriage took the greatest repug- nance to his wife and threatened her with a knife. During four years his marital attentions were purely of a menacing character, and at the end of that time he fell into errors of memory, and gran- diose ideas, which proved to be symptomatic of general paralysis, which soon closed in death. “Whether the sudden and excessive development of the sexual desire was the cause and precursor of the general paralysis, or whether it was part of the early symptoms of 224 skae’s classification of mental diseases.

the disease I shall not detain you now to inquire,” are the words with which Skae finishes his consideration of post-connubial insanity and his lecture. As far as we can ascertain, the pressing inquiry thus postponed was never subsequently undertaken, so that we are left in doubt as to Skae’s real view of the case. It is however introduced under the heading post-connubial insanity, as ” bearing upon several suggested points,” and not as an aid to differential diagnosis, and as it is as directly connected with the post-connubial condition as any other case adduced, we are at liberty to conclude that it is thrown in as another possible variety of post-connubial insanity, and our suspense as to what that disease is or is not has reached a climax. Let us in a final struggle for enlightenment, draw up in line Dr Skae’s contingent of post-connubials, and see what is to be made of them.

A case of congestive apoplexy. A case of acute dementia. A case of simple melancholia. A case of acute melancholia. A case of general paralysis.

“What is there we again ask in common in all these cases, except the occurrence of the disease after a particular event, with which it has not been shown to be specially connected ? We have known measles, and scarlatina, and small-pox come on immediately after marriage. Would it be advisable then to bracket these together as post-connubial exanthems ? Even supposing (what is by no means established) that in each of Skae’s cases the marriage and its accompaniments did have an actual causal relation to the mental disease, is it not clear that that causal relation was of an accidental and not of a necessary character ? Is it not clear that the orgasm or excitement was merely the spark applied to a train long laid and leading to a prepared catastrophe, and would not any other spark have done just as well ? Business losses are followed by cases of insanity, varying not more amongst themselves than Skae’s cases of post- connubial madness. Does anyone suggest that we should have the insanity of pecuniary embarrassments? Any lecturer on medicine who taught his students that because influenza, whoop- ing cough and diarrhoea sometimes follow a visit to the sea- side, they should be classed together as post-marine diseases, would be jeered out of his chair; and yet the Fellows of the Royal College of Physicians of Edinburgh were asked to listen to this disquisition about post-connubial insanity, and had presented to them as illustrative of that disease a set of cases that have no alliance with each other. We should much like to ask Dr. Clouston how the practical value of Skae’s system which he so vaunts is shown forth in this post-connubial group, how does it aid us in prognosis and treatment here ? Does he venture to say that the diverse cases assembled under it are to be similarly- treated, or that they are likely to pursue the same course and to have the same termination ? That they are to be similarly treated Dr Clouston has the boldness to affirm, and his practice is to give them all champagne, oysters, and nitro-muriatic acid with the view of calming their uxoriousness, another type of post- connubial insanity not mentioned by Skae. Lord Byron is not perhaps a good authority on uxoriousness, but on the passions lie is entitled to speak with some weight, and his dictum, which we commend to Dr Clouston’s consideration, is ” Eggs, oysters too, are amatory food.”

It must now, we believe, be tolerably plain that post-con- nubial insanity is a mere figment of the imagination, and a concoction of incompatibles. It is built upon the shifting sands of etiology. The first canon of classification that those things must be put nearest together which are nearest alike has been violated in its composition, while no minor practical advantage has been obtained. It must not be thought, how- ever, that this form of insanity is a peculiarly vulnerable point in Skae’s system, and that it has therefore been selected for more minute examination. Several other forms are equally wanting in stamina. Those forms that have been borrowed from other systems, have more cohesion in them and are less im- pressible by criticism, although even into some of them he has succeeded in importing an element of weakness; but wherever he has applied his own classificatory process, there he has con- structed a form that crumbles when touched or even when it is looked at. We are ready to show, and should do so here but that time is precious and patience limited, that half-a-dozen other forms are as irrational, unreal and impracticable as post- connubial insanity. As regards some forms, even Skae’s own pupils have faltered in their allegiance. ” Mania of Oxaluria,*’ writes Dr Batty Tuke, ” can hardly be regarded as a natural family, from the mere fact of the occurrence of the salt in certain cases, as its presence must be regarded as a consequence not a cause of such diseases as climacteric or idiopathic insanity; moreover, oxalates are generally found in cases where melancholia (not mania) is the leading mental symptom.” If the presence of oxalates in the urine is to be regarded as proof of this disease, then we have known a whole asylum full of patients to be labouring under it at one time, on the day after a rhubarb dinner. But very scanty information about it is to be procured, for all that Skae has to say about it is made up of a few extracts from Grolding Bird, Begbie, Bence Jones, and 226 skae’s classification of mental diseases.

other authors, and the only case quoted is supplied from the Eoyal Infirmary of Edinburgh, by Dr Grainger Stewart. We are not indebted to Skae for the knowledge that depression of spirits is a symptom of oxaluria, and that oxaluria is an occasional symptom of hypochondriasis. Dr Clouston argues on behalf of the late Dr Skae that even should the oxaluria, be the result of the disordered brain action instead of its cause, it would still be a fitting group basis in his system, that system which we are reminded again and again contains so much variety. ” While the authors of other systems have nearly all tried to go on some definite principle or other, to have their nosological pigeon-holes all of a size and all in a row, he was content to have much variety in everything about it.” Exactly so ! eschewing pigeon-holes he took refuge in the waste-paper basket, where one can have variety to his heart’s content. In answer to Dr Crichton Browne’s taunt that there are not a dozen asylums in England to-day in which Skae’s classification is employed, Dr Clouston retorts that there are not a dozen asylums in England in which many of its terms, and that somatic mode of looking at cases to which it gave so great an impulse, do not prevail. The retort gives the word of promise to our ear, but breaks it to our hope. It is denied that Skae’s classification gave any fresh impetus to the study of the bodily symptoms of insanity. Any old asylum case book will show that the somatic symptoms of insanity have all along had the lion’s share of attention, and the work of the phrenologists, Feuchtersleben and others, gave prominence to the somatic aspects of mental diseases while Skae was yet an undergraduate. Truly many of the terms of Skae’s classification are in use in every asylum in the land, but so they were before it was conceived, and so they will be after it is forgotten. These terms are they which were in circulation before Skae’s time, and which he appropriated, such as general paralysis, nymphomania, and not those which he himself coined, such as the insanity of pubescence and podagrous insanity. The reproach is that Skae’s classification?so practical, so useful, as it is said to be?has not been laid hold of by those who are likely to know a practical and useful article, and that its terms, its distinctive terms, and not those which it has borrowed, have not entered into asylum phraseology. A test of the extent to which Skae’s system has made way occurs to us, and we take up a sheaf of Asylum Reports that is lying upon the table, the last that have come to hand. We shall not burden our pages with the titles of these reports, but a list of them shall be supplied to Dr Clouston should he desire to possess it. Suffice it to say that the fasciculus includes thirty-four English reports in not one of which is Skae’s classification adopted, and two English reports in which its influence is apparent; eleven Scotch reports, in six of which the classification is mental, in two of which no classification is attempted, and in three of which Skae’s classi- fication is employed; four Irish reports, with no trace of Skae’s classification in them ; and twenty-six American reports, from which all recognition of it is absent.

It is all very well for Dr Clouston to protest that Dr. Maudsley in each successive edition has seemed to make more and more of it; that Blandford has assigned it a good place amongst other systems ; that Hack Tuke has given praise to it; and that Bucknill has incorporated its nomenclature in his own classification. Does he pretend that anyone of these eminent medical psychologists, has fully adopted it, and made use of it ? Can he name one convert to the classification in France, Ger- many, or America? Can he name an English convert who has not been a pupil of Skae’s? Do not Laycock, Sankey, Lockhart Robertson, Harrington Tuke, Monro, Lalor, Duucan, Rogers, Parsey, Hitchman, Boyd, Lauder Lindsay, Jamie- son, and a host of other leaders in the medico-psychological speciality, abjure and repudiate it? Did not Dr Crichton Browne’s attack upon it give lively and wide-spread satisfac- tion, because it embodied adverse criticism which had passed across the minds of many, but which, neglecting Captain Cuttle’s advice, they had not made a note of? Until Dr. Clouston can dispose of these interrogatories he need not trouble himself with special pleadings. Dr Mitchell’s decla- ration, again quoted, that Skae’s classification has taken hold of the medical mind, ought not to be repeated until the com- ment already made upon it?that it has no adequate warrant ?has been combatted. Dr Mitchell offers no proof of the allegation, except that papers have appeared in the medical journals with headings drawn from Skae’s nomenclature, but he has not taken up the challenge to point to any such papers that have not been by Skae’s own pupils. The hold on the medical mind must be down in the unrevealed depths of consciousness, as the spoken utterances of the said mind have been decidedly adverse to the system. But a greater authority than Dr. Mitchell has spoken on this matter, and by his deliverance we are content to abide as to the progress made by Skae’s system, and the acceptance accorded to it. Dr Clouston himself has summed up the matter by assuring us that Pinel and Esquirol’s five famous genera are ” still adopted in medicine, literature, jurisprudence, and official statistics.” Where, then, is Skae’s foothold ? In Morningside.

Dr Crichton Browne’s objection that Skae’s system with- 228 skae’s classification of mental diseases.

draws attention from clinical observation is branded as an empty calumny, and is dismissed as undeserving of serious disproof. It is even darkly hinted that such a slander is enough to disturb Skae in the ” eternal science,” which is Dr. Clouston’s dreary conception of another world, and we almost expect the table to tilt as we repeat the slander, and vigorous raps out of the eternal silence to admonish us for our temerity. But magna est Veritas, so we valiantly rehearse the so-called calumny, and maintain that Skae’s system does withdraw atten- tion from clinical observation, as every mainly etiological system must. To what is clinical observation directed? To symptoms! symptoms ! symptoms! What at the bedside must etiology and pathology necessarily be ? Why, to a great extent, clinical hearsay and clinical conjecture. But Skae’s system is founded upon etiology, and to it, therefore, symptoms must be of minor interest. A large majority of medical men are bent upon relieving suffering and curing their patients, and only to a few is given that higher enthusiasm that pursues knowledge for its own sake. Now, what to the majority of medical men is the great stimulus to the minute and persevering observance of symptoms? Why, the desire to recognise, to name, to classify the malady for which their advice is sought; to predict its course, and to modify its progress. Will that stimulus remain if the first words of the patient or his friends suffice to justify the recognition, naming, classification, prognosis, and treatment ? Which medical man is most likely to carry on minute clinical observations, he who by a study of the symptoms has to make out for himself in a particular case, through the mental and motor impairment, that there is organic dementia, due to a clot and softening involving the superior temporo-sphenoidal gyrus, or he who, being told that the patient’s illness dated from a blow on the head, is able to say off-hand traumatic insanity ?

The allegation that an etiological system discourages clinical work ought not to- require vindication. The inevitable ten- dency of such a system must be to take from the shoulders of the physician his proper responsibility, and to relieve him from the obligation of laborious investigation. So dangerous is etiology in this respect, that several well-known surgeons and physicians decline to hear the histories of the casas brought to them until after they have made their first examination, so that they may note symptoms with minds free from that bias so often misguiding and deluding that is apt to be given by that mixture of guesses and grumbles, in which history so often con- sists.

It is much to be deplored that Dr Clouston’s ill-chosen encomiums so often necessitate references to Skae that are not of that graceful character that we should now alone wish to indulge in. We have a respectful, admiring recollection of him as a man of capacious intellect and genial sentiments, who commanded the affectionate regard of all who approached him, but we cannot bring ourselves to say that he was a great clini- cist. That he had all the talents that go to the making of a great clinicist we cordially allow, but that he put these talents out to usury we cannot admit. His mode of work was essen- tially unclinical, and Dr Clouston, in extolling him as a clinicist, must have forgotten that many who attended Skae’s lectures and demonstrations in the wards of Morningside still survive. Their reminiscences, as far as we can ascertain, bear out the statement that he was never seen to make a genuine clinical examination, or to use an instrument of precision, but that his practice was, most dexterously, in a few sentences, to rifle a patient’s mind of its madness, and then with jaunty re- flection and acute foresight, and sometimes with broad humour, to comment upon the madness- and the madman. He paid much more attention to the mental symptoms in his asylum than in his classification, but lie was never a clinician, which is all the more to be regretted as some of his assistants would evidently have been much benefited by that clinical training which it was in his power to give. Of his classification it must still remain true that it withdraws attention from clinical ob- servations, and is thereby pernicious.

We have before alluded to the circumstance that Dr. Clouston doubtless inadvertently, but very unfortunately, has overlooked one of Dr Crichton Browne’s most formidable assaults on Skae’s classification, his objection that it has not one but several bases. We again refer to the matter because the objection properly comes in here in Dr Crichton Browne’s essay, following that which we have just considered as to the in- fluence of the system in interfering with clinical work, and also because we believe it has great intrinsic importance, and is destructive to the system if not rebutted. It is impossible to find any parallel to Skae’s system in this respect, and we fancy its advocates will be puzzled to point to an instance in which the ground of classification is thus changed, and it is indeed difficult to conjure up a corresponding absurdity. Were a lecturer on the theory of music to announce, ” I shall classify musical sounds as follows : some by their loud- ness, others by their pitch, others by their timbre, others by the musical instruments by which they are produced, and others by the colour of the hair of the men playing these musical instru- ments,” his method thus propounded would not be more gro- 230 skae’s classification of mental diseases. tesque than Skae’s, nor more barren of edification. Can there he any likelihood that a system which is constructed partly on etiology, partly on mental symptoms, partly on bodily symptoms, partly on pathological changes, partly on constitutional condi- tions, and partly on epidemic prevalence, will have consistency or strength, or will help us to understand the diseased modifications of consciousness in living organisms? Till Skae’s pupils can so transform his system that all its groups shall have one kind of basis, they need not seek for it the sympathy of thinking men ; at present there is no plan of construction in it. It is only a fortuitous concourse of atoms.

Turning to the fourth charge brought against Skae’s classifi- cation by Dr Crichton Browne, that it is incomplete, we find that a plea of guilty has been entered, but that as usual the precise nature of the charge has been misapprehended. “I admit the proposition that the system is not yet complete,” and this Dr Clouston says without perceiving that the admission is fatal to the system and proves it to be no system at all. His idea evidently is, that the charge amounts to this that the system is not perfect, and is capable of amendment, but it really is a much more serious indictment, setting forth that the system does not cover the ground which it professes to occupy, but leaves large tracts unenclosed. Imperfection would not be a valid objection, for that applies to all human work. That some groups required to be subdivided, that the frontiers of others needed rectification from time to time, that even new groups had to be added in the progress of years, would not vitiate the system, would, indeed, rather commend it; for science is nothing more than systemised experience, and as experience enlarges, science becomes more precise, and terms and names must be varied and corrected. In a progressive science, like medical psychology, such variations, corrections, and extensions, must be frequent to keep pace with the march of discovery, with ideational differentiation and evolution, with the changes in the character of disease wrought by ever changing environment, so that if Skae’s svstem required entire re-arrangement every ten years, as we are told that the system of chemical nomenclature will do, we should not have a word to say against it on that account. Our objection is, not that it is imperfect and may require modifica- tion, but that it is incomplete and does not include a large proportion of the object matter that it professes to classify, this imperfection being the result of an inherent vice in its consti- tution. Chemical classification is imperfect, and will undergo modification, but it is not incomplete. There is no substance that cannot at present be referred to certain known elements. There is none with reference to which the chemist has to say, I cannot name the constituents of this substance and do not know to what class to refer it. What should we think of our classification of the parts of speech if we were constantly coming upon words that would not fit into any one of them ?

Here are one hundred insane persons to be arranged in groups which will enable us to understand their relations to each other, their tendencies, their prospects, and the remedial measures which should be adopted. Let Dr Clouston try his plan and see the result. He sorts them out into thirty-four groups, and then on his own showing twelve cases remain that cannot by any exercise of ingenuity be forced into any one of these. Let a follower of Esquirol try his plan (which, remark, we do not consider satisfactory nor recommend), and see what a very differ- ent result is obtained. He separates them into half-a-dozen lots, and not a single case is over, as an unclassifiable residuum. It is hard to imagine what would be thought or said in a general hospital, if in twelve per cent, of all the cases admitted the malady could not be recognised nor named. Probably a change in the medical staff would not be long delayed.

Dr Clouston says that Skae’s classification breaks down in only twelve per cent, of cases, but others allege that it fails utterly in thirty per cent. Perhaps the truth lies between the two, although it is no great matter where it lies, for is it not now obvious that the said classification, however applied, and to whatever extent it may avail for the assortment of cases, is still worthless ? It has been told in Gath and published in the streets of Askelon (though, of course, we cannot vouch for the truth of the rumour) that rash attempts to apply the system in the wards of Morningside in the presence of illustrious strangers have eventuated in painful exhibitions of its impo- tency.

As to the incompleteness of the system, not more need be said than that it “is another indication that he (Skae) never took a wide all-embracing survey of the district which he undertook to map out for the benefit of mankind. He made erratic inroads upon it, and penned off irregular allotments here and there, but he left some territory untouched, and the end of his labour is confusion and bewilderment.”

Having granted that Skae’s system is incomplete, its champion advances to do battle with another objection with which it has been assailed. “The next objection we come to,” he remarks, ” is, that there is no gradation, social arrangement, nor harmony” in it, a sentence that caused us swimming in the head, and induced a nightmare vision of Skae’s happy family of thirty-four forms, socially hobnobbing and singing Gaudeamus igitur in the Cave of Harmony. Mo gradation, 232 skae’s classification of mental diseases.

social arrangement, nor harmony; we should never have fathomed this had we not gone to Dr Crichton Browne’s paper, and there the riddle was read. What Dr Clouston treats as one objection is really two that are kept carefully separate, and that we might almost say are alternative objections. The first is that there is no gradation in it; the second, that there is no serial arrangement, which Dr Clouston, by no slip of the pen or printer’s error, converts into social ar- rangement. He has evidently never heard of serial arrangement; so, although the term is twice made use of, and although the periphrastic equivalents, ” linear order of progression,” ” lines of normal evolution,” are also used, all that he can make of it is social arrangement or harmony?the word harmony not being employed at all by Dr Crichton Browne in connection with this objection, but being a gratuitous addition of Dr. Clouston. The allegations of want of social arrangement or harmony he designates an sesthetical objection, which gives us a little insight into what he conceives the aesthetical emotions to be, and reminds us that there is one of them, the sense of the ludicrous, which he stimulates almost too copiously in his readers. About the absence of serial arrangement?-which he has not comprehended?he has not of course a word to say, but, like a retiring cuttle-fish, he shelters himself behind a squirt of ink, reproducing from Dr Crichton Browne’s critique a number of sentences that have no bearing-upon the point in arbitration. It is quite curious to notice how ready Dr. Clouston is to adopt his antagonist’s ijosissima verba when any psychological point is in dispute, and how rarely he favours us with his own philosophical lispings. And it is even more curious to notice how pertinaciously lie shrinks from any logical exercise of thought. The argument now pressed home is, that Skae’s classification has neither gradation nor serial arrangement, and is therefore unsound; and that argument is met by some quotations to this effect?that the phenomena of disease are varied; that the functions of the nervous system cannot be classified with the same precision as can animals and plants, and that forms of insanity merge into each other. The quotations are irrelevant; the difficulties that they point to are supposed to have been overcome by Skae, who is maintained to have seen through the varied phenomena of disease into the permanent kernel, and to have classified with precision thirty-four forms of insanity that do not merge into each other, or at least not to any such extent as to render a boundary line impracticable. The question now is, not as to the classification of cases of insanity or nervous diseases, but as to the classification of alleged forms of insanity, and the inference is that as these forms are not classified, are not classi- fiable, and are not even arranged in strata corresponding with the stratification of nervous structure and function, their inventor did not know what scientific classification is, and ought not to have attempted it.

There is a reciprocal alliance between classification and reasoning?the one presupposes the other. Seasoning is the classification of relations, but this involves the classification of the things or attributes between which these relations subsist, and the intuition common to both reasoning and classifica- tions. We are compelled to classify and to reason, alike by objective conditions and by the necessities of the thinking sub- ject itself, and we cannot stop short in the process at a first generalisation. If we did so, how could the infinity of nature ever be brought down to the finitude of man ? But we cannot do so. By a first generalisation we obtain a number of classes of resembling individuals. By a second generalisation we com- pare these classes together, observe their similarities, abstract from their differences, and bestow on their common circum- stances a common name. By a third generalisation we again perform on these second-classes the same operation, and thus ascend to very wide notions. And this is just what Skae has not done. By a cursory indiscriminating survey of insane persons, he made out, or believed he made out, thirty-four classes made up of individual cases, but any survey of these classes in order to trace out agreements and differences between them, he never essayed to make. He added class after class, just as it occurred to him, and without any reference to its place in his system, and sought not to advance from the many and the special to the one and the general. Where only thirty-four classes are concerned the want of gradation and serial arrangement is not so instantly perceived as when a larger body of particulars have to be dealt with, although even then the want is generally damaging to the character of the system. But let anyone conceive what natural history would be if the species or genus was the highest term, and he will then comprehend how practically essential, as well as philosophically reasonable, gradation of classes is. The want of gradation in Skae’s system?all ques- tion as to serial arrangement being discarded?although at first pronounced by Dr Clouston an SBsthetical objection, is imme- diately afterwards looked at in quite another light. He has thought over the matter, or taken advice regarding it, and, changing front, responds to it that Dr Batty Tuke, in what is of course ” an excellent paper,” published in 1870, has shown how naturally Skae’s groups fall into seven classes arranged by Dr. Tuke. Dr Clouston therefore admits the gravamen of Dr. Crichton Browne’s charge, and acknowledges that when the classification was originally promulgated there was no gradation in it. He hastens to show that it has been since freed from this blemish, but in doing so he mistakes the true gist of the charge. It is of no great moment whether or not Skae’s forms have now been assorted into groups of higher generality. The point is, that they were not so at first assorted, but were thrown out in most admired disorder, a fact which indicates that Skae’s method was unmethodical, and that he had no clear notion of what he was doing, and no genius for classification. To call a writer who hurled thirty-four distinct unassociated forms of insanity upon his profession ” the Cullen of psychiatric medi- cine,” is either fulsome adulation or blind prejudice. But the approval with which Dr Tuke’s grouping of Skae’s forms is now received is somewhat singular. If that grouping is so excel- lent and supplies so grievous a want in Skae’s system, why was it not sooner adopted ? Dr Tuke’s paper embodying that grouping was published in 1870, and Skae’s Morrisonian Lec- tures were written after that and were published in 1873, being edited by Dr Clouston. But in these Lectures no notice is taken of Dr Tuke’s grouping, and in the first lecture the thirty- four forms are again enumerated in the old style, with no attempt at gradation. And when we come to scrutinise Dr Tuke’s grouping, we find that it is not a grouping of Skae’s forms, but of something altogether different. Dr Skae and Dr Tuke have been to the same fountains, Morel and Yander Kolk, but each has drawn water in his own pail. Tuke does not accept Skae’s basis of classification, and takes exception to several parts of his nosology; he excludes six of Skae’s forms from his table, and introduces three little forms on his own account, of which the most remarkable is limopsoitos. In so far as it does contain a rational arrangement of sub-classes into classes, and in so far as it is more consistent throughout, Tuke’s classification is greatly superior to Skae’s; but it possesses defects that are all its own, and dwindles into insignificance when looked at from the first round of the philosophical ladder. It is something, how- ever, that it recognises the necessity of some gradation such as that which prevails amongst the natural order of plants and animals. To appreciate the difference in practical value between a true and a spurious gradation in the matter of mental disease, one has only to contrast that of Grrisenger with that of Dr Batty Tuke.

Having now finished our scrutiny of Dr Crichton Browne’s general objections to Skae’s classification, and Dr Clouston’s rejoinders to these objections, we may briefly dispose of four special objections to the details of it, which out of many such Dr Crichton Browne has thought fit to send to the front. These are :?1. That the classification contains a group named idio- pathic insanity, in which a heterogeneous mob of cases is as- sembled. 2. That some of the etiological groups are founded, not on definite or true causes, but upon a course or period of life. 3. That consequences of disease are confused with causes. 4. That physiological processes are regarded as morbific agencies. None of these objections has Dr Clouston been able to refute, and to none of them has he been able to make a fair show of resistance. That idiopathic insanity is an anomaly in such a system as Skae’s, as indeed all its critics have agreed, he cannot deny; but he evades the true force of the argument,and maintains, what is not disputed, that idiopathic insanity actually exists, failing to see that what he had to do was to justify the presence of such a group in Skae’s etiological and pathological system. That system starts with the assumption that there is no idio- pathic insanity, and ends with the conclusion that it is a com- mon form. It is due, we are informed, to moral causes ; but do not moral causes play a part in the production of a score of other forms, and on what principle are they fastened upon here and reflected elsewhere ? Idiopathic insanity is indeed a Gehenna, as Dr Batty Tuke has called it. It swallows up the in- cidentals and sundries of some confused transactions, and what these incidentals and sundries are no accountant, chartered or unchartered, has as yet made out.

That several of Skae’s forms are founded not on a definite cause but on a whole period of life, will not be contradicted, and that such foundation is treacherous cannot be disproved. Clim- acteric insanity, Dr Clouston explains, is not intended to include every species of mental derangement occurring in the male between 50 and 60, and in the female between 40 and 50. What it does embrace he is not careful to tell us, but he implies that it is marked out by a definite group of mental symptoms; we have ransacked Skae’s writings, but with no better fortune than to find ranged under climacteric insanity every mental symptom of every variety of melancholia, with maniacal outbursts, homicidal impulses, and hallucinations to boot. The most striking characteristic and peculiar symptom of climacteric insanity is, the fear of undefined evil, which is just the nebulous stage of all kinds of melancholia. Not a single bodily symptom of climacteric insanity has this great stickler for the somatic view of insanity or his sturdy henchman to give us. By mental symptoms alone must it be known. Now we will undertake to produce patients labouring under all these mental symptoms at every age from 15 to 70, so that there is nothing in them, and they cannot be the means of diagnosis. What is it 236 skae’s classification of mental diseases.

then which, added to these symptoms, enables a Skaeite to decide that this is climacteric insanity ? The period of life ; that is the sole test. Then as the period of life alone justifies the diagnosis, and as no distinctive mental symptoms are given, the period of life combined with mental symptoms of any kind constitutes climacteric insanity, and all cases of insanity occurring at that period are climacteric, which is what Dr Clouston denied. But again suppose that the symptoms are distinctive, and of themselves enable a diagnosis to be arrived at without regard to the period of life, why should the period of life be tugged in at all ? Why should not a name founded upon the essential distinctive symptoms be chosen, and not one founded upon the non-essential undistinctive epoch? On the horns of this dilemma we leave Dr Clouston, warning him that should he extricate himself, worse trials are in store for him in connection with this question of the propriety of making long tracts of time a ground of classification of mental diseases.

The conversion of consequences into causes of mental disease is more than once apparent in Skae’s classification. Amenor- rhcea is not in itself an efficient cause of insanity, else how many young women would be insane. Skae himself says it is sometimes the effect of insanity, and yet he draws up a group of amenorroeal lunatics?many of whom sutler from dysmenorrhea and menorrhagia, and who present very pro- miscuous symptoms, to wit, those of hysterical mania, acute melancholia, dementia, and moral insanity. In this distinct form there is probably in every case an hereditary predisposition, and in some cases an exciting cause which has lighted up the mischief, so what the amenorrhoea has to do with it we do not very well comprehend. No doubt amenorrhoea may be a cause of insanity, but, in the cases adverted to by Skae, it is much oftener a result of the nervous disorder. The best reason that Skae can give for saying that amenorrhoea causes insanity is that the patient herself is often of that opinion.

As to phthisical insanity we may remark that we are familiar with the euphoria which often illumines the progress of consumption, and with the delirium that sometimes checkers its later stages, but that we have never encountered that phthisical insanity which is Dr Clouston’s own peculiar pro- perty, and which was at one time so prevalent in that asylum over which he now presides. Defective hygiene has been the source of much phthisis in asylums, and is still responsible for some, and of course certain classes of lunatics are by virtue of their debility and habits, more likely to suffer from it than others. In some thoroughly well ordered asylum phthisis is less prevalent than in the general community from which the asylum population is drawn, which would scarcely be the case were phthisis a cause of insanity to the extent that Dr Clouston has averred. It may be, as he says, that Dr Crichton Browne has not fully allowed for the fact that it is the tubercular diathesis, and not the lung de- generation to which he attaches importance ; but if he insists so much on this why does he in the last Report of Morningside put all the deaths from phthisis under the thoracic and not under the constitutional diseases ? It is an appalling record, that contained in Dr Clouston’s paper on Tuberculosis and Insanity, showing that tubercular deposit was found in 282 out of 463 cases, or in 60*9 per cent.

That it was not a happy thought to make a physiological process give a name to a disease will be admitted by most people. If we have lactational insanity because insanity comes on during nursing, we might have menstrual insanity because it took origin during the monthly period, or the insanity of digestion, because it supervened on a full stomach. But we shall not press this nor other objections?because it is only vindictiveness to slay the slain. Skae’s classification has in our judgment had its quietus, though whether it will pru- dently betake itself to the eternal silence remains to be seen. By the controversial prolixity which has been imposed upon us by the loose disjointed reasoning that we have had to follow up, if reasoning it can be called, no space has been left to us for the lighter and more congenial task of adequately complimenting Dr Clouston on the peroration of his paper. The finished beauty of his style, the delicate subtlety of his irony, the winning sweetness of his manner, the stately dig- nity of his objurgations impart to that peroration a rare charm, and must long make it a model of chastened invective. If Dr Crichton Browne on reading it did not ring for sack- cloth and ashes, then he is other than we have taken him to be. ” Far from us, and from our friends be such frigid philosophy ” as would stand unmoved in the presence of bathos, or behold without emotion the ruins of common sense. We dash down our pen in the wildest agitation, resuming it how- ever to remind Dr Clouston that a bludgeon is not a cutting weapon, and to assure him that although he does not specify the kind of milk which he thinks suitable for “medico- psychological babes,” and which is doubtless supplied un- adulterated at Morningside, we have no difficulty in guessing its real nature. We are confident that it is a sort of milk very suitable for weak stomachs, and that it smacks deliciously of the national emblem of Scotland. N. M

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