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CONSCIOUSNESS may be lost: unconsciousness; or weakened: clouding of consciousness; or exaggerated: hyper


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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 enfeeblement of consciousness upon the emotional state 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 enfeeblement 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 the 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, his 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.

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Exaggeration of consciousness. consciousness. Morselli distinguishes two kinds of hyperconsciousness: "Hyperconsciousness with diffuse introflection, when the self-consciousness is referred to organic phenomena, as in melancholiacs, hypochondriacs, and paranoiacs, giving rise to illusions and hallucinations of general sensibility and of cœnæsthesia; and hyperconsciousness with concentrated introflection, when representations are perceived and emotions experienced with an abnormal intensity: hence the ecstasy of spontaneous or induced (hypnotic) hallucinatory states."1 Generally hyperconsciousness is but partial: certain sensations or certain representations absorb the conscious psychic activity to the partial or complete exclusion of others.

1 Morselli. Loc cit., p. 754.


An act of memory comprises three distinct operations: 1. The fixation of a representation;

2. Its conservation;

3. Its revival, that is to say, its reappearance in the field of consciousness.

These may be disordered together or singly; hence the three forms of amnesia:

A. Amnesia by default of fixation (or simply amnesia of fixation), also known as anterograde amnesia; B. Amnesia of conservation;

C. Amnesia of reproduction.

The latter two affect impressions previously acquired and constitute retrograde amnesia; there are therefore two varieties of retrograde amnesia: 1) by default of conservation, and 2) by default of reproduction.

A. Amnesia of fixation. Anterograde Amnesia. - The power of fixation (Merkfähigkeit of German authors) is dependent upon the distinctness of the preceptions. Therefore all conditions in which perceptions are vague and uncertain are accompanied by a more or less marked amnesia of fixation; such is the case in epileptic deliria and in acute confusional insanity.

Distinctness of perception is therefore a condition necessary for the normal working of memory; it is, however, not in itself a sufficient condition. An impression, though very clear and very precise at the moment, may not fix itself upon the mind. Thus a patient having the polyneuritic psychosis may understand perfectly the questions put to him, execute properly the orders that are given him, so that on a superficial

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