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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.

ment of the whole body in convulsion, providing there be a regular order of march in the fit, still admits of consciousness being more or less completely retained throughout the attack. Here we must suppose that the brain gains a certain degree of preparedness

a for the attack and consciousness is not so much disturbed but that memory of the important event of the fit endures in the after conscious state. The manner of return to full normal consciousness after the fit furnishes not a little clue whether memory of what transpired in the fit will be recalled. The analogy of the amnesia following dreams is a case in point. Thus most dreams are forgotten on waking; the vividness of a dream does not mean it will be remembered. In a close analysis of many epileptics one

a finds plenty of evidence that a sort of cerebration goes on in many fits, as in ordinary sleep; in both but a small part of the cerebration may or may not be consciously preserved.

The majority of epileptics undoubtedly recall that they have had seizures, although in many cases this would be inferred from their sensations, attitudes, etc. The more violent the convulsive movements, the longer the after stupor, the less is remembered. These considerations, however, concern not so much the retention or abolition of perception in the attack, the object of our thesis, as retrograde or ordinary amnesia with partial return of memory. This latter phase is only a part of our special problem. Even though complete abolition of all reflex activity in the fit does not obtain, consciousness may be entirely lost; it can not therefore serve as a criterion. The reverse of this is seen in the trance state. Again, the corneal and pupillary reflex may be retained in grand mal and consciousness may not be retained. Adequate proof is equally difficult from the standpoint of recollection.

Finally, we may summarize our views as follows: Those cases of epilepsy in which consciousness can be fully proven to persist in the attacks are either minor epilepsy, petit mal epilepsy, epileptoid states or psycho-motor equivalents, partial or abortive epilepsy of organic or non-organic origin, or, not epilepsy at all, but one of the many protean types of grand hysteria.

Bearing these remarks in mind, I shall now cite briefly three very unusual cases of convulsive epilepsy with full retention of consciousness. I have carefully studied these cases for several years.

CASE I.-L B., 17 years old. Epileptic and neurotic heredity. The patient was robust and apparently normal until she developed epilepsy at 13. Her idiopathic partial attacks developed in the right arm, starting from the biceps. She has an epileptogenic zone area, as marked in this picture of the patient. Any slight irritant in this area precipitated an attack whenever the centers were ready for the fit. The attacks may be prevented for a time by keeping the arm quiet and free from irritation. These partial attacks were invariably followed by transitory exhaustion palsy, both sensory and motor in character. The attacks could be inhibited in part by day, but occurred twenty or thirty times a single night. Inasmuch as the patient had no mental stigma of epilepsy, never lost consciousness in attacks and bromide increased the number of attacks per day, the condition was thought to be hysteric in character, with an hysterogenic zone. The above condition had been present for about two years when I first saw the attacks. The attacks, which has now become general, were as follows. I saw several hundred of them and the following was typical.

The patient is awakened out of a quiet, sound sleep by a tonic spasm or cramp in the right biceps. The spasm quickly spreads in a few seconds in the following order of march: right arm, right leg, left arm, left leg and face. The spasm is then a slow gyratory contortion, throwing the patient from the bed, the eyes are wide open and staring. The attack ends in a few coarse choric spasms, during which latter phase the patient may be able to prevent injury to arms and hands by clinging to the bed. Tongue is bitten and urine is voided. The patient is then able to relate all details of what happened in the attacks. In several of these attacks the patient was able to answer simple questions and give directions for holding her and protecting her with clothing while in this highly dramatic type of fits. The breathing is labored and the conversation is necessarily fragmentary. The attacks are painless, in sharp contrast to Case III. In about one-tenth of the entire number the patient is totally unconscious in the attacks and has no after recollection of the fits.

An unconscious attack is as follows: Patient, as before, was awakened from sound sleep by the biceps contraction, the shoulders were elevated and the head was drawn down and forward on the chest, then the shoulders were lowered and the arms were abducted from the body. The right wrist was flexed toward the body, the fingers were in main en griffe position throughout the tonic period for five or six seconds. Pupils were dilated and irresponsive as usual. Consciousness was maintained up to this point as usual. The fury of the clonic spasm, more than usual, increased suddenly in violence at this point. The left hand was broken from its grasp on the bed rail and was thrown about wildly, clutching at the air. The feet in equino-varus were crossed, the face became cyanosed, patient said, "No use! no use!” and immediately lost consciousness. Eyes rolled upward and inward, urine was voided, and frothing at the mouth in stertor period followed. To those who believe loss of consciousness is necessary, the epileptic genuineness of the last-described attack must be fully convincing. Taken by themselves, appalling as they were, I am sure no one would hastily designate the attacks of the first-described epilepsy as minor epilepsy. It is true they were a little less severe, as a rule, than the lastdescribed, where consciousness was lost, but this was by no means always the rule. The case is also one of the very few illustrating the presence of an epileptogenic zone.

Case II is that of a young man of 18, who has had idiopathic grand mal attacks since childhood. Mental state, feeble-minded. He has had prolonged periods of status and post-epileptic exhaustion. The attacks, as may be seen from the accompanying photograph, are general and grand mal in character. The order of march of the fit was too rapid for analysis. It seemed to start in the right hand and face first. In the attack photographed here, one of thirty for that day, the patient answered many simple questions, told me the attack paineď him in the right arm, that his head ached and that his “ neck was breaking.” His utterances were not distinct, as both sides of the face were in rigid spasm at the time. Tongue was bitten and urine was voided.

Case III is that of a young man of 24, of epileptic and neurotic heredity. His grand mal epilepsy, of unknown origin, began at twelve years of age. The attacks continued weekly for one year, then ceased altogether for three years. The epilepsy reappeared at 16 and continued to occur three or four times a year until he was 23 years old, at which time the ordinary grand mal epilepsy, classic in all respects, was supplemented by granď mal attacks of focal onset and a regular order of muscular march over the entire body. These attacks were attended by full consciousness during the attacks and complete recollection of all the horrible details of the fits. The attacks had a tendency to group themselves in serial and status periods. The patient has had status of 300 conscious attacks daily on several occasions. The grand mal character of the attacks may be proven by the pathetic description the patient has given me in a recent letter. I will give it verbatim, as it is a document of more than ordinary human interest.

“Dear DOCTOR.—I will try to describe my feelings during the attacks of epilepsy.

" First of all I feel a knocking from the back of the neck to the top of the head, then there is either an itching sensation in the throat or a sense of fullness, or a feeling as though there was a turning on of water in the throat and shutting it off suddenly. A few seconds after, my head swims, the right side of my face screws up, and then when I feel this I know I am in for an attack. My right hand stiffens, the arm twists and then my right leg grows stiff, then the left arm and left leg and, finally, the whole body grows stiff and rigid. My head then turns to the right side, jerking and twisting all the time. I cry and groan, the pain of the twisting of the head off the shoulders is so great. Just as the head twists, so the whole right arm knots up and twists above my head. The grinding, twisting pain is horrible. When this painful agony is just at its worst, the stiffening over all the body lessens and my limbs are thrown, knocked about and bruised. Sometimes when the spasm leaves the left arm first, I reach over with it and hold the right arm and the head from the hardest thumping.

AMERICAN JOURNAL OF INSANITY, Vol. LXVI, No. 2.

CASE I.-L. B. Genuine convulsive epilepsy with retention of conscious

seizures. Outlined area right arm is an epileptogenic zone.

CASE II.--J. P. Photograph of a grand mal epileptic fit during which there was retention of consciousness.

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