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The clearest evidence of the relationship of inattention, confusion, stupor, and coma is that patients may pass through each of these states as they become comatose or emerge from coma The authors have not observed such a relationship between coma and delirium except possibly in patients suffering from bacterial meningitis, certain drug intoxications or withdrawal states, or hepatic stupor and coma, which in some few instances may be preceded by a brief period of delirium Drowsiness and Stupor In these states, mental, speech, and physical activity are reduced Drowsiness denotes an inability to sustain a wakeful state without the application of external stimuli Inattentiveness and mild confusion are the rule, both improving with arousal The patient shifts positions in bed or chair The lids droop without closing completely; there may be snoring, the jaw and limb muscles are slack, and the limbs are relaxed This state is indistinguishable from light sleep, with slow arousal elicited by speaking to the patient or applying a tactile stimulus Stupor describes a state in which the patient can be roused only by vigorous and repeated stimuli, at which time he opens his eyes, looks at the examiner, and does not appear to be unconscious; response to spoken commands is either absent or slow and inadequate Restless or stereotyped motor activity is common in stuporous patients and there is a reduction in the natural shifting of positions When left unstimulated, these patients quickly drift back into a sleep-like state The eyes move outward and upward, a feature that is shared with sleep (see further on) Tendon and plantar re exes and breathing pattern may or may not be altered, depending on how the underlying disease has affected the nervous system In psychiatry, the term stupor has been used in a second sense to denote an uncommon condition in which the perception of sensory stimuli is presumably normal but activity is suspended and motor activity is profoundly diminished (catatonic stupor) Coma The patient who appears to be asleep and is at the same time incapable of being aroused by external stimuli or inner need is in a state of coma There are variations in the degree of coma; in its deepest stages, no reaction of any kind is obtainable: corneal, pupillary, pharyngeal, tendon, and plantar re exes are in abeyance, and tone in the limb muscles is diminished With lesser degrees of coma, pupillary reactions, re ex ocular movements, and corneal and other brainstem re exes are preserved in varying degree, and muscle tone in the limbs may be increased Respiration may be slow or rapid, periodic, or deranged in other ways (see further on) In still lighter stages, sometimes referred to by the ambiguous term semicoma, most of the above re exes can be elicited, and the plantar re exes may be either exor or extensor (Babinski sign) Moreover, vigorous stimulation of the patient or distention of the bladder may cause a stirring or moaning and a quickening of respiration These physical signs vary somewhat depending on the cause of coma For example, patients with alcoholic coma may be are exic and unresponsive to noxious stimuli, even when respiration and other vital functions are not threatened The depth of coma and stupor, when compared in serial examinations, is most useful in assessing the direction in which the disease is evolving Relationship of Sleep to Coma Persons in sleep give little evidence of being aware of themselves or their environment; in this respect they are unconscious Sleep shares a number of other features with the pathologic states of drowsiness, stupor, and coma These include yawning, closure of the eyelids, cessation of blinking and swallowing, upward deviation or divergence or roving move-

ments of the eyes, loss of muscular tone, decrease or loss of tendon re exes, and even the presence of Babinski signs and irregular respirations, sometimes Cheyne-Stokes in type Upon being awakened from deep sleep, a normal person may be confused for a few moments, as every physician knows Nevertheless, sleeping persons may still respond to unaccustomed stimuli and at times are capable of some mental activity in the form of dreams that leave traces of memory, thus differing from persons in stupor or coma The most important difference, of course, is that persons in sleep, when stimulated, can be roused to normal consciousness There are important physiologic differences as well Cerebral oxygen uptake does not decrease during sleep, as it usually does in coma Recordable electrical activity EEG and cerebral evoked responses and spontaneous motor activity differ in the two states, as indicated later in this chapter and in Chap 19 The anatomic and physiologic bases for these differences are only partly known