[Functional pathophysiology of consciousness].

Consciousness (Latin conscientia "moral conscience"), according to the English philosopher John Locke (1632-1704) [103], is the awareness of all that occurs in the mind of a person, whereas the American philosopher John Searle (2000) defined it as "inner qualitative, subjective states and processes of awareness". In modern science it is defined as a continuous state of full awareness of the Self and one's relationship to the external and internal environment, describing the degree of wakefulness in which an organism recognizes stimuli. This widely discussed biological term for complex neuronal processes that allow an individuum to recognize itself and its environment and to act accordingly, has been and still is the subject of much research in philosophy and natural/neuroscience. Its definition is often used for awareness and recognition, too. While the Egyptians in the papyrus Edwin Smith already recognized the brain as the seat of consciousness, René Descartes (1644 [36]) believed its special structure should be "a small gland in the middle", but the anatomical structures and physiological processes involved in consciousness were elucidated only in the middle of the 20th century. Neuronal substrates include several functional networks that are hierarchically organized and cooperate functionally. The lowest level is the mesencephalic formatio reticularis and its projections to the thalamus that were identified als ascending reticular system (ARAS) by the classical experiments of Moruzzi and Magoun, whereas later analyses of patients with impaired consciousness provided further insights. The mesencephalic ARAS as motor of the function of higher structures projects 1. via the reticular thalamus diffusely to the cortex, 2. via hypothalamus to the basal forebrain and limbic system, and 3. to the medial raphe of the brainstem and locus coeruleus and their diffuse cortical projections. The reticular system is stimulated directly and indirectly via numerous collaterals from important somatic and sensory pathways and acts as a control system of neuronal activities of the cerebral cortex. The principal function of the ARAS is to focus our alertness on specific stimuli or internal processes, which run via complex neuronal cell groups and numerous neurotransmitters that influence various aspects of consciousness and wakefulness. Stimulation of the ARAS produces an arousal reaction as the electric correlate of consciousness; its destruction causes coma and related states. The highest level are cortical (prefrontal and association) networks for recognition, motor activity, longterm memory and attention, the left hemisphere being considered as the dominant one. Different levels of consciousness are distinguished: 1. hyperalertness, 2. alertness (normal state of wakefulness), 3. somnolence or lethargy, 4. obtundation with tendency to fall asleep, 5. stupor, 6. coma and its subtypes, like akinetic mutism, apallic syndrome or persistent vegative state, locked-in syndrome, delirium, and catatonia. They are caused by damages in various functional levels of the brain, by psychogenic factors or experimentally, and are accompanied by characteristic neurological and psychiatric disorders. The relevant morphological lesions can be detected by electrophysiological and imaging studies. The bases of functional anatomy and pathophysiology of consciousness, its cognitive aspects and its major disorders, their causes and functional substrates with reference to sleep and both spontaneous and iatrogenic disorders of consciousness are critically summarized.