Coma and other disorders of consciousness
Jouvet M.
Handbook of Clinical Neurology Vol.3. P. J. Vinken and G. W. Bruyn , eds. North-Holland Publishing Company. Amsterdam,(1969)
TABLE OF CONTENTS

Introduction

Physiopathological basis of coma (introductory remarks)

Nervous structures necessary for consciousness

Periodic physiological dissolution of consciousness: sleep and coma

From experimental to clinical neurophysiology

Physiopathology of nervous lesions responsible for coma

Aetiological classification of comas and of disturbances of consciousness of organic origin

Symptomatological classification of coma

Tentative anatomoclinical classification
FIGURES

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Physiological Basis of Coma (introductory remarks)

The physiopathology of coma poses three main problems :

(1) Which structures are required for the conscious appreciation of a stimulus? In terms of neuro physiology, we may say that conscious appreciation depends on the integrity of cortical structures, provided that the waking system of the brainstem is itself functionally intact.

(2) Conscious appreciation is not a stable and permanent phenomenon. It is subject to a physiological dissolution by reason of the presence of sleep "systems" which periodically counteract the waking system. Now, do the sleep systems play a part in the production of a comatose state ? The answer would appear to be "no" as organic lesions of the sleep systems in animals cause no apparent disturbance of consciousness.

(3) The last problem is histopathological: what are the exact mechanisms by which neurological lesions lead to a comatose state ?

Reactivity and perceptivity : it is important to make a distinction between the two basic concepts lead of reactivity and perceptivity (Alajouanine 1957) as we shall later rely on these notions to assess the depth of coma in man and animals.

Reactivity brings into play mechanisms which are present since birth, the seat of which is subcortical; these are activated via the telereceptors (the eyes and ears) or via the nociceptive stimuli.The arousal reaction, the orienting response (rotation of the head towards the source of an auditory stimulus) and the facio-vocal reactions to pain are all part of the reactivity complex.

Perceptivity on the other hand implies the response of nervous mechanisms acquired by learning. It is a response to stimuli of a more complex nature (words, gestures, writing) or to simpler ones (elementary conditioning in the case of blinking response to a threat). We now know that these responses, which depend upon recent and long-term memory, require a certain degree of cortical integration . The integrity of the cerebral cortex, however, is a necessary but not a sufficient condition to ensure normal perceptivity. We must go further, therefore, in our neurophysiological analysis of the nervous mechanisms which are essential for the awareness of an external event.

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