Reflections on coma: Man deprived of his consciousness

Abstract

In this paper the authors reflect on the phenomena produced by the surprising communication between the unconscious of a therapist and that of a comatose patient. In a particularly disturbing context, when the patient’s sternum is open and exposed, the therapist communicates empathically with the comatose person, identifying the patient’s inexpressible experience and generating signs of a response from him in the form of the blinking of his eyelids. The absence of any reaction to pain, a pathognomonic sign of the comatose condition, could be related to the splitting‐off of the trauma, as if the situation were frozen, through a denial of the sensory and neurological perception of pain – a kind of self‐anaesthesia as a defence against the catastrophic anxieties raised by the threat of the return of the primary trauma. Starting from this encounter a relationship is formed whose guiding thread emerges in the shared illusion of a regression that makes it possible. It involves a process of returning to the past and a re‐actualization of the past that includes the question of its change through representation.

Key words:

• comatose condition
• regression
• splitting
• trauma
• perception of pain
• denial

1. Translated by Andrew Weller.

1. Translated by Andrew Weller.

Notes

1. Translated by Andrew Weller.

2. Elisabeth, a 30 year‐old woman suffering from Wolff‐Parkinson‐White syndrome, had been hospitalized following a cardiac arrest, the exact duration of which was unknown as she had been resuscitated by a member of her family, and now lay in a deep coma. Generally speaking, the indications taken into account for determining the extent and gravity of the cerebral injuries are the duration of the cardiac arrest and the consecutive cerebral anoxia. On the 40th day of her hospitalization, the professor of the unit drew attention to a position of pronation of her upper limbs, which is a clinical sign of a decorticated brain. This meant any hope of a resumption of brain activity was henceforth excluded. I was at the back of the group making the medical visit, when I noticed an abandoned newspaper lying at her feet, with headlines announced a surprising event. Was it as a final salutation that I read her the headlines out loud, adding: “I’m afraid so, Elisabeth,” as if she was my interlocutor? A very slight movement of certain facial muscles was now visible, whereas hitherto her expression had remained impassive. I do not think there was any reason to suppose that the event I had read out had moved her. Was it the fact that I had called her by her name? In the protocol for evaluating the depth of a coma, calling the patient’s name figures at the top of the list, but in this case it elicited no emotion from the examiner. I communicated my impression to my colleagues in intensive care and to the nursing staff, in part to reassure myself that I was not mistaken and that my perception was not an illusion. From that point on we slowly and gradually witnessed the emergence of consciousness and the recovery of her motor and intellectual activity. This example is given to illustrate the gulf that exists between the world of an unconscious patient in a state of total dependence on his or her environment and the difficulty, inherent to human nature, of identifying with them and of addressing a person who is considered to be ‘absent’.

3. Maria, a woman in her 50s, had fallen into a coma for six months following a cranial trauma suffered in a car accident. In spite of the improvement in her vital parameters and the fact that she was no longer in intensive care, she remained in a coma. The caregivers’ efforts to wake her up, which even including bringing in colleagues who spoke her mother language, had no effect. Having been called in for a consultation, I learnt that her husband, who had been driving at the time of the accident, had been killed instantly. She had been living in her husband’s country for no more than a year and could not speak the national language well. Seated beside her, I took her hand and called her by her first name. Convinced that she was in a regressive state, I spoke to her in her mother language in a soft voice, as if I was waking an infant. She opened her eyes after I had explained in simple words what had happened, that she was currently in the hospital, and that she was now out of danger. She asked me for some water.