With GRIESINGER the reins of Hippocratic teaching were at last fully recovered. Again came recognition that mental disease and brain disease are synonymous; and as both are determined, like other forms of illness, by natural causes, so are they to be investigated and treated by natural means. GRIESINGER emphasised the necessity of studying the brain changes associated with the psychoses, and recommended the anatomical spirit as the safest antidote against the Spiritualistic doctrines, which he was pleased to refer to as the "anointed pectoral psychiatry."

GRIESINGER was the first to urge the erection of special psychiatric clinics, as we now know them. He was keenly alive to the need of enlightened instruction in mental disease as a part of medical education, and was an earnest patron of reform with regard to the legal status of the insane. In short, the broad paths which GRIESINGER laid out are those which psychiatrists have since been following, and the goals he indicated are precisely those toward which we are still striving.

In his own country realisation has gone far, but on this side of the water, unhappily, many of the distressing circumstances of which he complained more than sixty years ago, have still to be reckoned with. Are we not compelled to admit that the following words, written the fourteenth of August, 1845, are only too true even to-day? "The neglect of psychiatry among physicians, and particularly in the universities, shows daily its unhappy consequences. They appear in the diagnosis and treatment of fresh cases on the part of practicians, to whose care the mentally ill are entrusted, often long before they are brought to the alienist in the hospital. Still more conspicuous are these effects in the forensic activities of physicians. The State which permits no one to apply a bandage until he has demonstrated his ability and practical experience, allows physicians who have never seen a mental case, or perchance for the first time on arriving at court, to debate offhand, over the head of the accused, the subtlest questions concerning doubtful psychic states, and to declare an opinion which may determine a death sentence or acquittal. The absolute uncertainty of such judgments has rightfully brought them into disrepute with the jurists." "

The facilities of instruction in mental medicine have considerably

14 Loc. cit.

widened since GRIESINGER'S day, and are constantly expanding; but the world is perhaps grown no more honest than it was, and one feels a subtle sympathy with the aforetime situation, when some of our twentieth century expert testimony comes to mind.

The clinical psychiatry of GREISINGER was modelled in general after that of CULLEN and PINEL. He recognised three great groups of psychoses:

(1) Conditions of psychic depression, including hypochondria and melancholia, with both stuporous and excited forms.

(2) Conditions of psychic exaltation, including maniac and other states of excitement.

(3) Conditions of psychic weakness, including confusional states, paranoid conditions and various dementing processes.

This classification has, through the natural development of the science, long been superseded; but it was in large measure the clear insight of GRIESINGER, brushing aside a priori arguments to make room for facts, and upon the basis of these facts constructing a scientific system in which should be correlated the data of anatomy, pathology, physiology, psychology and bedside observation, which opened the way for the phenomenal growth of the end-century school, which has brought psychiatry such a good step onward.

XII.

We have finished a rapid survey of some of the achievements of mental medicine during the past three thousand years, closing with the establishment of what we may speak of as the current period of the modern epoch, embodying the work of the present and the last generations. Within the narrow limits of such a review, it has seemed better to select a few of the more conspicuous names and more significant movements and to dwell somewhat upon them, than with greater haste and brevity to pass over a multitude of facts and names. The arbitrary choice of this method must be the excuse for many considerable omissions, particularly in dealing with the modern epoch.

With three general observations we shall take leave of our subject.

First, we have seen that psycho-pathology and theology have always lived in uncomfortably close relations to each other. In

the beginning, and later during the Dark Ages, both the symptomatology and therapy of mental disease reflected the ascendency of religious ideas. Since the days of HEINROTH these ideas have vanished from our therapeutic standards, while they painfully persist as a potent factor in the symptomatology of insanity. The thought-values of a people are for the most part cast in the minds of the learned few. They are then gradually, slowly taken over by the masses of the people and become part and parcel of common consciousness. Once so assimilated, they cling with extraordinary tenacity, even long after they have become obsolete among the leaders of thought. Such has ever been the case in the history of the succession of religions and the transformation of religious ideals. In Christianity there are two particular doctrines: namely, that of the native helplessness and wickedness of the human individual, which must be atoned for, vicariously or otherwise; and that of the fear of the wrath of God which shall visit vengeance if such atonement be not realised. And these two doctrines, so pernicious in their possible influence, among the credulous, upon the healthy balance and normal euphoria and joy of living, so entirely out of harmony with the rationalistic spirit of the twentieth century, still lurk in the public mind, and often dangerously near the surface. In many hapless patients they furnish the chief bloom of their psychotic flora. With the gradual spread of rationalistic modes of thought among the people, and the implied dying out of belief in the oppressive dogmas of so-called orthodox religious systems, we may perhaps hope for the final elimination of this particular element of morbid potential.

The second observation concerns the growth of our science in broad terms. In accordance with the circumstances just referred to, we find that psychiatry at the beginning of the nineteenth century was practically at the point where it was arrested during the early years of the Christian era. But the spirit of inquiry is never totally extinct. With the erection of suitable hospitals for the accommodation of mental cases, every opportunity was offered for the scientific study of insanity. Under the guidance of the theory of psycho-physical parallelism, the facts of the new science began to arrange themselves in order. Anatomy, physiology, pathology, psychology, all contributed their parts; the concepts of etiology and pathogenesis have come to have somewhat more definite mean

ing; and the way has been opened for intelligent attempts at prophylaxis, the highest object in any field of medicine.

Finally, a third observation, by way of closing tribute to the masters of other ages. In reviewing the various clinical descriptions of disease, we are often struck by the modernness of ancient views, or more correctly, the antiquity of alleged modern views. A single instance shall suffice. We have seen that the mutual relations of affect depression and exaltation, described by KRAEPELIN under the term maniaco-depressive insanity, have been known from the earliest times. The close association of these states or their unity in a single disease was discussed by ARETAEUS in the first century A. C. ALEXANDER of TRALLES in the sixth century voiced a similar opinion. SENNERT in 1641 referred to the possible alternation or succession of phases of depression and maniac excitement. WILLIS in 1667 expressed the definite view that mania and melancholia are so closely related that they may mutually replace each other, or that one condition may take on characters of the other (mixed states). In 1684 BONET spoke of the succession of these contrasting states, as for example in a patient who was maniacal during the summer and melancholiac during the winter. BONET even proposed calling such conditions "maniaco-melancholiac" insanity. BOERHAAVE in 1739 repeated the ideas of his predecessors regarding the association of depressive and excited states. MORGAGNI in the same century insisted upon the impossibility of distinguishing frank clinical pictures in every case, so often did the symptoms of one phase alternate with, succeed or mingle with those of its opposite. LIEUTAUD in 1765 declared the opinion, so often heard before, that mania is only an exaggerated stage of melancholia. PINEL in 1801 entertained independently the same views. GRIESINGER in 1845, in his chapter on melancholia, said, "The transition to mania, and the alternation of the latter with depression, are very common. Not infrequently the entire illness consists in a cycle of both forms, which often succeed each other with complete regularity." Thus at length culminated the two most familiar functional mental abnormalities, after a progress of eighteen hundred years, in the folie circulaire of FALRET (1854), and the maniacodepressive insanity of KRAEPELIN.

CONSCIOUS EPILEPSY.*

BY L. PIERCE CLARK, M. D., NEW YORK CITY.

As a general rule loss of consciousness occurs in grand mal epilepsy some time during the fit or spasm. In slight seizures, that of minor epilepsy, consciousness may merely be impaired or even retained. This statement should, however, include also the minor or partial attacks of Jackson's and Bravais'.

Cases of so-called genuine grand mal epilepsy have been reported at rare intervals with full retention of consciousness by Newmark, Doussin, Radcliffe, Reynolds, Maxwell and Tamburini. Careful analysis of these rare cases, however, usually leaves much to be desired in the completeness and genuineness of the attacks. Even though one admits these cases as idiopathic epilepsy and not hemiplegic epilepsy, one is forced to believe that the cases are idiopathic epilepsies with local or Jacksonian onset with a regular order of muscular march. Indeed every grand mal attack must have a local onset; the march of the fit is so rapid, however, that detailed study is usually impossible. A localized maximum irritability of the cortex must be postulated in most cases of genuine epilepsy. Notwithstanding we have a perfect right to shift the burden of proof for the loss of consciousness in genuine idiopathic epilepsy (no adequate explanation for that phenomenal mystery is yet at hand), one may summarize the theory of the general loss or retention of consciousness in epilepsy as follows: In minor epilepsy the cortical discharges are either too slight in degree or too slow in cortical discharge to abolish consciousness. In partial convulsive epilepsy the discharges may be both sudden and severe in degree, and yet, because a part of the cortex is left functionally intact, consciousness will be preserved in greater part. Moreover, even in so-called genuine grand mal epilepsy, as in my cases, the complete involve

* Read at the sixty-fifth annual meeting of the American MedicoPsychological Association, Atlantic City, N. J., June 1-4, 1909.