Consciousness may be lost: unconsciousness; or weakened: clouding of consciousness.

Unconsciousness And Clouding Of Consciousness

Unconsciousness exists physiologically in dreamless sleep, and pathologically in coma and in complete stupor.

Clouding of consciousness represents the fundamental element of many psychoses. It is always coupled with more or less complete disorientation.

A complete orientation implies the integrity of the following three notions:

1. The notion of our own personality (autopsychic orientation of Wernicke);

2. The notion of the external world (allopsychic orientation of the same author);

3. The notion of time.

These three notions may disappear together or singly. We shall see later that in certain affections, notably in delirium tremens, the orientation of time and place is lost, while that of personality remains intact. The patient is ignorant of the fact that he is in a hospital ward, does not appreciate his surroundings, and cannot give even approximately the real date. But he knows that he is Mr. X., following such and such an occupation, so and so many-years old, born on such and such a day, etc.

Allopsychic disorientation, or loss of the notion of the external world, is often coupled with many hallucinations. Some authors see in the two symptoms a causative relation; the hallucinations transport the patient to an imaginary world, thus making him lose the notion of the real world. Experience does not bear out this hypothesis: (1) because the orientation may be perfectly preserved in spite of intense and unceasing hallucinations; (2) because, inversely, it may be profoundly disordered without there being hallucinations of any kind; (3) because in most of the cases in which these two symptoms are associated the disorientation precedes the psychosensory disturbances.

Influence Of Clouding Of Consciousness Upon The Emotions And Upon The Reactions

Unconsciousness and clouding of consciousness find expression, in the emotional sphere, in indifference and dullness; and, in the psychomotor sphere, in aboulia which in extreme cases may amount to complete inaction.

If complicated by symptoms of excitement, hallucinations and illusions, delusions, or anxiety, clouding of consciousness is accompanied by emotional phenomena and reactions characteristic of these symptoms. It is important to remember above all that the disorder of consciousness may impart to the reactions of the patient a more or less impulsive character; hence their brutal and sometimes ferocious nature.

Diagnosis Of Clouding Of Consciousness

Unconsciousness is generally apparent from the absolute indifference of the subject who fails to react even to the strongest stimulation. However, it is necessary to exercise great caution in many cases. We shall see later on that certain patients, the catatonics, present every appearance of unconsciousness and may nevertheless preserve perfect lucidity; the disorder of consciousness is here only a seeming one. Often one is obliged to wait before coming to a decision; when the attack passes off, the patient himself may tell of his former condition, either declaring that he has no recollection of what passed during the attack - in which case the unconsciousness was real - or explaining that, though perceiving external impressions, he was unable to react - in which case the unconsciousness was but a seeming one.

Clouding of consciousness is determined by putting to the subject a series of questions concerning his age, occupation, the date, the surroundings, and the persons about him.

States Of Obscuration

By this term are designated those pathological states in which lowered consciousness is the dominant feature. States of obscuration vary greatly in their aspect, and probably also in their nature. All, however, possess one feature in common: they leave behind almost complete amnesia for the occurrences that have taken place during their entire duration. But the degree of consciousness at the time of the attack itself is very difficult to determine, and probably varies greatly.

Often patients afflicted with violent delirium have but an extremely confused notion of their surroundings, and their acts bear the character of complete automatism. Such are cases of epileptic delirium.

Others, on the contrary, perform complicated acts, such, for instance, as are involved in a long voyage, in a sober and reasonable manner and without attracting anybody's attention; and still they may have no subsequent recollection of these acts. This occurs in certain pathological absences which are most commonly observed in epilepsy but which may also be encountered in various psychoses.

It can scarcely be assumed that in these two cases the disorders of consciousness are identical.