Clinical Notes Illustrative of Consciousness in Epilepsia. By C. H. Hughes, M. D., St. Louis, Mo. Reprint from The Alienist and Neukologist, St. Louis, April, 1881. Art. VIII.—Clinical Notes Illustrative of Consciousness in Epilepsia. By C. H. Hughes, M. D., St. Louis. T? LIZA ELLEN C., aet. 12 years, had spasms in infancy, which often recurred throughout the period of dentition. Of late years she has had very pronounced epilepsia, the attacks of grande vial recurring about every fortnight, with frequent epileptoid seizures in the intervals. This girl came under my medical care, February 1st, 1878, and, under vigorous treatment, speedily improved from a state of apparently helpless imbecility and untrust- worthiness, after her paroxysms, to one of good average intelligence and reliability, so that the rest of her family could safely entrust her alone in the house, and permit her to go to school a part of each day. In the following August, after having been six months free from seizures, epileptoid paroxysms were displayed in evanescent attacks of psycho-motor paralysis, recurring every few days, of which the patient was wholly conscious, making “ desperate ” but fruitless mental efforts, “ like one in a nightmare ” (as she afterwards stated), to overcome her momentary immobility of limbs and tongue, and attract attention. (This girl’s mother died of consumption, at 41 years of age; her grandmother, of apoplexy; grandfather, of typhus fever; and one of her uncles was insane. Her father is temperate, has pursued various laborious occu- pations and appears healthy. He can give no more accurate record of the family history than that here given.) 2 C. //. Hughes. A change in the form of bromides employed, conjoined with mild galvanism of the cervical sympathetic, caused these remains of the epilepsia to disappear ; and the girl is now (March io), though still under steady treatment, free from all reminders of her malady. Theo. B., age 20, came under treatment in June of 1879, with grande mal without aura. His first seizure, in May, was caused by overwork in the harvest field and mental depression resulting from failure to get pay for his work. He has been free from all manifestations of the disease since July, 1880; had a paroxysm of conscious automatism about the first and a brief aphasic spell in the middle of September, 1880. Annie R., aet. 29, school-teacher, has had spells in which, on feeling a sense of weight on the top of her head, she would fall down but remained conscious. Her left arm would at these times be convulsed; often, also, her eyelids. At other times, while teaching she has felt herself become motionless, her eyelids to close and would momentarily loose consciousness and, on coming to, would hear the scholars say: “Ah! look there, Miss R. is going to sleep,” recalling the lately registered impression of this exclamation on her auditory centers. Her sister has spells of vertigo—falls down unconscious; and her father had, in his life time, occasional attacks of epilepsia gravior. After some of her spells she has headache and is stupid. Three years before she came under my observation the reflected irritation of an ulcerated and prolapsed os uteri increased the number and intensity of her attacks. A vigorous specific treatment for epilepsia caused all evidences of her disease to disappear; and, without asking my advice, the patient moved to a distant State and married. The clearly recognized connection of these milder symp- toms, with marked evidences of the graver malady and the fact that a bromide plan of treatment was successfully employed in all of them must silence all cavil as to their epileptic character. While unconsciousness, in petite mal, Cojisciousness in Epilepsia. 3 is the rule, there are, certainly, numerous exceptions, and these exceptions are altogether too frequent and too certainly demonstrable to permit of the dogmatic asser- tion, that, when there is not unconsciousness, there can be no epilepsia. The unilateral epilepsias and the spinal epilepsias are, themselves, convincing confirmations of the truth that consciousness is not the sine qua non of the status epilepticus. The cases we give are recent, and the “ doubting Thomases ” may place their mental digits in the holes which clinical facts make in their fanciful formularies of true epilepsia. Had we time, we might pile Pelion upon Ossa, and Ossa upon Olympus, until the proof would rise so high that the most imperfectly-visioned might discern it. Everyone, familiar with all the phases of epilepsia, knows how common, under judicious treatment, are these abortive features. These abortive displays, under treatment, are as well entitled to a place among the varieties as those modifications which appear without medical modification ; like the following: Hattie B., aged 24 years, about the time of her cata- menia, has frequently recurring momentary spells of speech- lessness, during which she hears people about her talking, and can repeat what they have said, and has excessive downward irritation of the chorda tympani nerve and saliva- tion. Preceding these spells, a peculiar sensation is experi- enced in her fingers. At the time of these spells, an impulse prompts her to sit down. About once a year she has very bad spells, in which she falls down and knows nothing. She had spasms in infancy and early childhood, and later, at about 12 years of age, she had a series of violent seizures, which were accompanied with falling and unconsciousness. These ceased to recur more fre- quently than about once a year. Hattie’s mother used to have frequent dizzy spells, and an aunt had “ falling fits.” Hattie is. a domestic, and these abortive attacks come on her while about her work, but, being determined, she does not always lose consciousness. 4 C. //. Hughes. Other clinical confirmations of epileptoid disease with- out unconsciousness have been recorded by us {vide Alienist and Neurologist, April, 1880,) and others still might be here enumerated from our own experience, but the testimony would be needlessly cumulative. The re- cognized and conceded automatism of certain undoubted epileptics in which there is every appearance of a con- ciousness sometimes, though exceptionally, quite complete, coupled with a psycho-motor excitation and consequent impulsion to travel or perform accustomed, as well as unaccustomed journeys and acts, should, even without the proofs here given, dispel that incredulity which has led some to deny the possibility of consciousness in epileptic states. The idea of unvarying loss of consciousness should take its place with that ancient and exploded, but once thoroughly accredited falacy, which gave to this malady the name of Morbus Sacer. A more or less prolonged state of central non-impressi- bility to excitation—a delayed periperal mental activity tardy response to impressions which, ordinarily, promptly excite the ideational centers of the cortex into action—one or all together, characterize epileptic seizures. When only the latter state exists, the patient may be a mute spectator, as in epileptic aphasia, and in a manner conscious, of the crippled state of his ideo-motor centers. Every intelligent Physician ami Medical Student should subscribe for “ The Alienist and Neurologist.” PROSPECTUS FOR 1881. m HANKFUL for the encouragement and generous judgments it lias received in the past, the Alienist and Neurologist enters upon another year with a hopeful, and, it is believed, useful 'U-PRl Is?/future before it. Its subscription list and the number of its c)1 i® cont1-ikntors and pages have steadily increased since the day of k@ i) it3 inception, till it now counts its friends anil collaborators in till the States at home and in many Countries abroad. It will eon- i tinue its endeavors to promulgate sound teaching respecting the grfls nature and treatment of the Neuro-Psychic and Nervous dis- T eases. It will continue to maintain that psychiatry and neurology, like tlfe study of the vascular system, are essential parts of the trunk, rather than special branches of medicine, and will endeavor to bring these departments concisely, prominently and satisfactorily before the General Profession. Due prominence will be given to electrology, alcoholism, meconism, cliloralism, and the pathology, management and treatment of inebriety, as within its legitimate province. Though the writings of savants will often find place in its pages, their contributions will be mainly such as the practicing physician cannot well ignore. No effort or necessary outlay in the conduct of the Alienist and Neurologist will be spared to deserve and retain its present degree of professional confidence, and to merit still greater approbation and support. It will be the chief aim of this journal to so present the clinical aspects of neurology, that the medical student and the physician just starting out in his career, may intelligently comprehend them. Tiik Alienist and Neurologist is not so much a journal for specialists, as it is a special journal for general practitioners and advanced students of medicine, in which may be found more that pertains to morbid psychology and neurology, than may be found in any general medical journal, and so presented as to be of special value to every physician who aspires to the highest attainable practical advancment. The Medico-Legal aspects of such subjects as come within its scope will receive full consideration. Its columns will continue open to the candid and impersonal discus- sion of all unsettled questions in psychological and neurological science. Contributions of merit from competent sources of experience invited. C. H. HUGHES, M. D., EV. E. CARRERAS, Publisher, Editor. 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