Book Review

Plum and Posner's Diagnosis of Stupor and Coma

N Engl J Med 2007; 357:727August 16, 2007

Article

Plum and Posner's Diagnosis of Stupor and Coma
(Contemporary Neurology Series. 71.) Fourth edition. By Jerome B. Posner, Clifford B. Saper, Nicholas D. Schiff, and Fred Plum. 401 pp., illustrated. New York, Oxford University Press, 2007. $79.50. ISBN: 978-0-19-532131-9

Long before the public fascination with coma began, the state of unconsciousness had a primal appeal to physicians of all stripes. The understanding of coma stretches from Baron Constantin von Economo's observations of brain-stem encephalitis in 1917, to Hans Berger's discovery of brain waves in the 1920s, to Giuseppe Moruzzi and Horace Magoun's experimental anatomical work of the 1940s. Yet writings on the bedside observations of coma were littered with pompous prose about apoplexy (including some written by William Osler) until the clinical investigations of Donald McNealy and Fred Plum, which led to the publication in 1966 of the first edition of The Diagnosis of Stupor and Coma. This was a monograph in the truest sense — it was focused and taut, and every word was instructive. It united for the first time a theoretical understanding of the arousal system in the upper brain stem with clinicopathologic case studies, and in doing so created the modern examination for coma that is based on the patient's pupils, eye movements (the dreaded “doll's eyes”), and breathing patterns. Just as everlasting was the book's contribution to the education of medical students. The authors framed the neuroanatomy of the brain stem on a group of clinical signs that was understandable and amenable to memorization.

The fourth edition of this book follows the previous edition by more than 25 years, and enough has come to light in the fields of physiology, neurochemistry, and brain imaging to make the wait worthwhile. Much of the book's organization is the same as it was in the first edition. The exposition of the physical examination of the comatose patient is beautifully done, with many of the original figures preserved but updated. The pathophysiology of the structural causes of coma is also well illustrated and is punctuated by case descriptions. Clifford Saper's summary of the neuroanatomy and neurophysiology of coma is clear, analytic, and complete. The sections on prognosis and on metabolically induced coma, which will be of interest to general physicians, intensivists, and neurologists, are the most thorough that I have encountered and provide accessible tables and diagrams for clinical use. The same can be said about the complete and thoughtful explanations of psychogenic coma and catatonia.

Unique to this book is a section on the minimally conscious and vegetative states and recovery from coma, which borrows from the elegant work of Nicholas Schiff and includes up-to-the-minute concepts from the field of advanced neuroimaging. The thoughtful synthesis of these data points the way to what is likely to be the new neuroscience of the awake and comatose states. The authors do not try too hard to grapple with the issue of consciousness as a philosophical and psychological idea. The field of neurology has something to say about this subject, but an adequate vocabulary has not yet been established.

The middle sections of the book seem to overreach a bit by elaborating on the medical details of each of the many diseases that can cause coma, an approach that is similar to that of many textbooks on this topic whose authors are attempting to make them general works of neurology. The inclusion of this section is a small difference from the sparse elegance of the original book. I wish the authors had been more critical of — or had at least given their opinion on — entities with ambiguous or less well-delineated clinical correlations such as pancreatic encephalopathy, concussion, traumatic diffuse axonal damage, pontine lesions, endozepine coma, postoperative confusion, and several others that are included in the text but with unqualified summaries of the literature.

The book is a deserved paean to Fred Plum, who stimulated my own interest in neurology. Fred Plum and Jerome Posner wrote the first edition of The Diagnosis of Stupor and Coma to provide practical guidance, and the current edition is an admirable and pleasing successor. On the basis of pedigree, coherence, and thoroughness, it is currently the last word on the subject.

Allan H. Ropper, M.D.
Brigham and Women's Hospital, Boston, MA 02115