In Reply.—
Dr Reeves and Mr Jenkyn properly point out the importance of distinguishing awake but de-efferented patients from those in coma. However, the patient in question was in coma rather than in a locked-in state.
Repeated efforts to communicate with the patient by voice, gesture, mimicry, and attempted visual evocation of lid or vertical eye movements were made during his seven-month survival in the intensive care unit. No evidence of awareness or voluntary control of lid or eye movements could be obtained.
It should be emphasized that he was never observed to blink or to relax his lids at any time— day or night—during the seven-month course. Similarly, his eyes never ceased their dramatic vertical movements—an activity difficult to initiate and impossible to sustain voluntarily.
The electroencephalogram of patients in coma associated with bilateral pontine tegmental lesions frequently appears normal, and relative reactivity to afferent stimuli has been suggested as a
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