Neuronosology: historical remarks

Neuronosologia: observações históricas

HISTORICAL NOTE

Neuronosology: historical remarks

Neuronosologia: observações históricas

Marleide da Mota Gomes

MD, PhD, Neurologist, Associate Professor of Neurology, Epilepsy Program of the "Deolindo Couto" Institute of Neurology, Federal University of Rio de Janeiro, Rio de Janeiro RJ, Brazil. Department of History of Neurology, Brazilian Academy of Neurology, São Paulo SP, Brazil

^{Correspondence}

ABSTRACT

Classifications for neurological disorders have evolved from following the theory of the humors to modern anatomical pathology and, recently, to the germ theory that stared the etiological era, as seen in book content lists. The symptomatic approach towards neuronosology was widely used until the middle of the 19^th century. The following books are representatives of this: "De Cerebri Morbis (1549)"; "De anima brutorum (1672)"; and "A Treatise on Nervous Disease (1820-1823)". During the Enlightenment, "Synopsis Nosologiae Methodicae (1769)" had a great repercussion subsequently on neuronosology. "Lehrbuch der Nerven-Krankheiten des Menschen (1840-1846)" was the first systematic treatise in neurology, and "A Treatise on the Diseases of the Nervous System (1871)" was the first American textbook of neurology, and probably the first comprehensive one. The first Brazilian textbook was "Lições sobre as moléstias do sistema nervoso, feitas na Faculdade de Medicina do Rio de Janeiro (1878)". A presentation going from causes of death to the International Classification of Diseases and their importance for neurology is also made.

Key words: neurology, nosology, history.

RESUMO

A evolução da classificação de transtornos neurológicos seguiu desde a teoria dos humores até à anatomia patológica moderna e, recentemente, à teoria do germe, que iniciou a era etiológica, tendo em vista o sumário dos livros. A abordagem sintomática na neuronosologia foi extensamente usada até meados do século XIX. Os livros seguintes são representativos disso: "De Cerebri Morbis (1549)"; "De anima brutorum (1672)"; "A Treatise on Nervous Disease (1820-1823)". Durante o Iluminismo, "Synopsis Nosologiae Methodicae (1769)" teve grande repercussão posterior na neuronosologia. "Lehrbuch der Nerven-Krankheiten des Menschen (1840-1846)" é o primeiro tratado sistemático em neurologia e "A Treatise on the Diseases of the Nervous System (1871)" é o primeiro livro americano de neurologia, provavelmente o primeiro livro de neurologia abrangente. O primeiro brasileiro foi "Lições sobre as Moléstias do Sistema Nervoso, feitas na Faculdade de Medicina do Rio de Janeiro (1878)". São apresentadas desde Listas de mortalidade até as Classificações Internacionais de Doenças e a sua importância na neurologia.

Palavras-chave: neurologia, nosologia, história.

The main bases for medical classifi-cations have been the theories of the hu-mors (Hippocrates, 460-370 BC), modern anatomical pathology (Giovanni Bat-tista Morgagni, 1682-1771) and the germ theory (Robert Koch, 1843-1910)^1,2. The Hippocratic system primarily classified diseases according to symptoms, partic-ularly in terms of the parts of the body af-fected by diseases. The first of these clas-sifications was "Diseases of the head", as seen in the work Affections¹. Heralding the Enlightenment, Thomas Sydenham sug-gested that all diseases could be classified to a certain definite species in the same manner in which botanists were able to describe their plants (Genera Mor-borum, 1763)^3,4 . François Boissier de Savages de Lacroix established the first methodical nosology for diseases in Nosologia Methodica (1763), and listed 10 major classes of diseases, further broken down into 44 orders, 315 genera and 2400 species; the majority of the species were single symptoms^3-5. The fourth classification includes the spasmi. Indeed, the book covers several movement dis-orders and convulsions^6-8. However, the most commonly used classification system for diseases was published by William Cullen (Fig 1): many editions and revisions were published^9,10.

Books

Before the middle of the 16^th century, disease enti-ties were organized topographically, from the scalp to the toes. Epilepsy and headache were grouped with af-flictions of the hair and scalp¹¹. The most renowned an-cient books dealing with symptomatology of neurolog-ical importance are: De Cerebri Morbis (DCM) (1549), by Jason Pratensis; De Anima Brutorum (1672), by Thomas Willis; and A Treatise on Nervous Disease (1820-1823), by John Cooke. DCM was probably the first book de-voted entirely to brain disorders. The discourse of De Anima Brutorum (1672), by Thomas Willis, and that of his Pathologiae Cerebri made Eadi¹² conclude that Willis subdivided clinical neurology on the basis of a hypoth-esis of symptom pathogenesis, such that the symptoms fell into three groups on an anatomical basis regarding animal spirits: [1] they were normal in their intrinsic na ture, but were underactive, or overactive, in their func-tioning; [2] they had taken on abnormal explosive pro-pensities; and [3] they were otherwise abnormal in their intrinsic natures. John Cooke compiled what could be regarded as the first systematic coverage of the common neurological disorders: A Treatise on Nervous Disease di-vided the disorders into three sections: apoplexy, palsy and epilepsy based on the old schemes of broad syn-dromic categories of neurological disease^13,14.

Lehrbuch der Nerven-Krankheiten des Menschen, by Moritz Heinrich Romberg (1840-1846), is considered to be "the first systematic treatise on neurology". This au-thor divided neurological disorders into "Neuroses of Sensibility" and "Neuroses of Motility", based on the no-sology of William Cullen¹⁵. These two groups were fur-ther broken down: the first group into hyperesthesia (such as neuralgias and hallucinations) and anesthesia (such as blindness and deafness); and the second group into hyperkinesia (such as cramps and epilepsy) and aki-nesia (paralysis)¹⁶. This author was the first to use an an-atomical and physiological approach towards neurolog-ical diseases¹¹.

William Hammond's textbook, A Treatise on the Dis-eases of the Nervous System (1871), was the first Amer-ican textbook of neurology, and probably the first com-prehensive neurology textbook. It was divided into sections: introduction; I - diseases of the brain; II - dis-eases of the spinal cord; III - cerebrospinal diseases; IV - diseases of the peripheral nervous system; V - diseases of the sympathetic nervous system; VI - toxic diseases of the nervous system; and VII - certain obscure diseases of the nervous system. It went into nine editions and was translated into French, Italian and Spanish^17,18.

Leçons sur les Maladies du Système Nerveux faites à la Salpètrière, by Jean Martin Charcot¹⁹, provided the first sound nosography for neurology²⁰. The highlights of Charcot's work, which was based on the clinical- ana-tomical method, are the descriptions on Parkinson dis-ease, multiple sclerosis and tabes dorsalis dating from the 1860s, and on amyotrophic lateral sclerosis from the 1870s ^21,22.

The first Brazilian neurological textbook, by João Vicente de Torres Homem²³ (Fig 2), was also rooted in structure, neuroanatomy and neuropathology, as well as neurophysiology. This book is presented as a series of lessons, divided into three parts: encephalic diseases, medullary diseases and neuroses. Many of these lessons had already been published (for example in the journal Progresso Medico). The approach in the book is limited to brain disorders. There are eleven chapters: the first chapter covers general matters (the nine cases and the anatomical-physiological basis of the diagnosis); chapters II to VI cover "apoplectiform cerebral congestion", cere-bral hemorrhage, cerebral embolism and cerebral soft-ening due to thrombosis; chapter VII - covers aphasia; VIII - meningitis; IX - intracranial "tumor"; X - topo-graphical diagnosis of the diseases of the encephalon (clinical-anatomical correlation); and XI - treatments for cerebral diseases. However, this great Brazilian clinician did not accept the idea that microscopic creatures "could enslave all cellular pathology" ²⁴: this was a reverberation from the pre-germ theory that was also common to the works by Charcot and Hammond.

Today, books on neurology do not differ in their conceptual organization from the nosological paradigm given to us by Charcot and other pioneers of the 19^th cen-tury, as mentioned by Greenblat²².

From causes of death to the International Classification of Diseases

The roots of an international classification of diseases (ICD) went on being planted by John Graunt (1620-1674), William Farr (1807- 1883) and Jacques Bertillon (1851-1922)^3,25,26. Graunt is considered to be the first to analyze death records. He made a list of 83 causes of death, of which many related to neurology: apoplexy, convulsion, teeth, worms, palsy, falling sickness, sciatic, etc³. The first international conference convened in 1990 and revised the Bertillon or International Classification of Causes of Death that had been approved in 1893, with revisions occurring every ten years thereafter (Table). The Bertillon classification was based on the principle, mainly derived from work by Farr, of distinguishing gen-eral diseases ("Diseases of the Nervous System") from those located in a particular organ or at a particular ana-tomical site ("Diseases of Organs of Special Sense"²⁷). The first Diagnostic and Statistical Manual of Mental Dis-orders (1952) was created as an alternative to the ICD-6⁴. In the ICD -10, achieving a stable and flexible clas-sification was a matter of concern. There was a switch to alphanumeric notation (instead of numeric), and the chapter "Diseases of the nervous system and sense or-gans" of the 9^th Revision was split. ICD-10 contains "fam-ilies" of classifications, comprising specialty-based ad-aptations of the ICD. For example, neurology is allowed to provide extension of detail at the fifth character and beyond²⁸.

DISCUSSION

In this study, we weighed up neurological nosology as it came of age, beginning in the 1860s, on an ana-tomical -pathological basis. Thereafter, greater knowl-edge of the causality of disorders led to approaches of greater complexity, going from humoral theory to the germ theory, with advances within the fields of metab-olism, immunology, genetics and today, predominantly, molecular biology and biochemistry, along with environ-mental foundations. In relation to many disorders, redi-rection from solely nosological concepts that currently attempt to force pathophysiological and etiological ex-planations within a single domain, to concepts that do not ignore all other intrinsic, environmental or socio-cultural factors can be expected. Another classification problem is the categorization and naming of particular "species" as further information comes to hand: should lumping that favors similarities be jettisoned, in favor of splitting that creates new categories to classify samples that differ in key ways? Consequently, there will prob-ably be an ever-increasing number of classified diseases, especially coming from genetic and biochemical defini-tions, which will probably require total reclassification for many of them.

Received 10 October 2010

Received in final form 09 March 2011

Accepted 17 March 2011

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Publication Dates

• Publication in this collection
  19 July 2012
• Date of issue
  June 2011

History

• Accepted
  17 Mar 2011
• Reviewed
  09 May 2011
• Received
  10 Oct 2010