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The post-traumatic vegetative state
  1. A Zeman

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    Edited by Giuliano Dolce G and Leon Sazbon. Published by Thieme, Stuttgart, 2002, pp 158, €39.95. ISBN 1-58890-116-5

    This study of the vegetative state (VS), substantially written by Dolce and Sazbon with contributions from a number of colleagues, offers an interesting Mediterranean contrast to Brian Jennett’s recent survey of the condition that he and Fred Plum christened in 1972 (

    ).

    There is broad agreement on several key points: the clinical definition of the disorder; the prognostic importance of aetiology, age, and time spent in the VS (the likelihood of regaining awareness being higher after trauma, in younger patients, and falling as time passes); and its underlying pathophysiology—the VS is no longer regarded simply as a state of widespread cortical death, but rather as the result of a loss of physiological coherence between a number of brain systems (sensory, motor, and reticular) that must work in concert to generate awareness.

    There are two notable points of disagreement. The first may be semantic. The authors argue that although contact with the “outer world” is lost in the VS, contact with the “inner world”, mediated by phylogenetically ancient systems, survives. This is compatible with the standard view of the VS if the form of “contact” that the authors have in mind is basic metabolic and circulatory homeostasis mediated by the hypothalamus. That the authors have something more than this in mind is suggested by the remark that some patients in the VS enjoy “a relatively spared emotional life and contact with the inner world”. This intriguing if disquieting suggestion, and the evidence for it, is never fully explored.

    The second point of disagreement is more sharply defined. While accepting the very low probability of recovering awareness after spending one year in the VS, and the even lower probability of a good functional outcome, the authors describe the decision to withdraw nourishment in such patients as “an act of active abandonment”. They later compare such decisions to the elimination of “lives without value” in Nazi Germany. The international debate over the proper management of patients who have little or no prospect of recovery from the VS is clearly far from over.

    Although this volume contains a great deal of useful information, it is occasionally marred by puzzling passages that are likely to reflect linguistic problems.

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