Preface to the Fourth Edition
Fred Plum came to the University of Washington in 1952 to head up the Division of
Neurology (in the Department of Medicine) that consisted of one person, Fred. The
University had no hospital but instead used the county hospital (King County Hospital),
now called Harborview. The only emergency room in the entire county was at that hos-
pital, and thus it received all of the comatose patients in the area. The only noninva-
sive imaging available was primitive ultrasound that could identify, sometimes, whether
the pineal gland was in the midline. Thus, Fred and his residents (August Swanson,
Jerome Posner, and Donald McNealy, in that order) searched for clinical ways to dif-
ferentiate those lesions that required neurosurgical intervention from those that required
medical treatment. The result was the first edition of The Diagnosis of Stupor and Coma.
Times have changed. Computed tomography (CT) and magnetic resonance ima-
ging (MRI) have revolutionized the approach to the patient with an altered level of
consciousness. The physician confronted with such a patient usually first images the
brain and then if the image does not show a mass or destructive lesion, pursues a careful
metabolic workup. Even the laboratory evaluation has changed. In the 1950s the only
pH meter in the hospital was in our experimental laboratory and many of the metabolic
tests that we now consider routine were time consuming and not available in a timely
fashion. Yet the clinical approach taught in The Diagnosis of Stupor and Coma remains
the cornerstone of medical care for comatose patients in virtually every hospital, and the
need for a modern updating of the text has been clear for some time.
The appearance of a fourth edition now called Plum and Posner’s Diagnosis of
Stupor and Coma more than 25 years after the third edition is deserving of comment.
There were several reasons for this delay. First, the introduction and rapid development
of MRI scanning almost immediately after the publication of the last edition both
stimulated the authors to prepare a new edition and also delayed the efforts, as new
information using the new MRI methods accumulated at a rapid pace and dramatically
changed the field over the next decade. At the same time, there was substantial progress
in theory on the neural basis of consciousness, and the senior author wanted to incor-
porate as much of that new material as possible into the new edition. A second obstacle
to the early completion of a fourth edition was the retirement of the senior author, who
also developed some difficulty with expressive language. It became apparent that the
senior author was not going to be able to complete the new edition with the eloquence
for which he had been known. Ultimately, the two original authors asked two of their
proteges, CBS and NDS, to help with the preparation of the new edition. Fred parti-
cipated in the initial drafts of this edition, but not fully in the final product. Thus, the
mistakes and wrongheaded opinions you might find in this edition are ours and not his.
We as his students feel privileged to be able to continue and update his classic work.
One of our most important goals was to retain the clear and authoritative voice of the
senior author in the current revision. Even though much of the text has been rewritten,
we worked from the original organizational and conceptual context of the third edition.
Fred Plum’s description of how one examines an unconscious patient was, and is, clas-
sic. Accordingly, we’ve tried whenever possible to use his words from the first three
editions. Because the clinical examination remains largely unchanged, we could use
some of the case reports and many of the figures describing the clinical examination from
previous editions. Fred was present at each of the critical editorial meetings, and he
continued to contribute to the overall structure and scientific and clinical content of the
book. Most important, he instilled his ideas and views into each of the other authors,
whom he taught and mentored over many years. The primary writing tasks for the first
four chapters fell to CBS, Chapters 5 to 7 to JBP, and Chapters 8 and 9 to NDS. However,
each of the chapters was passed back and forth and revised and edited by each of the
authors, so that the responsibility for the content of the fourth edition remains joint and
several.
Most important, although the technologic evaluation of patients in coma has
changed in ways that were unimaginable at the time of publication of the earlier edi-
tions, the underlying principles of evaluation and management have not. The exam-
ination of the comatose patient remains the cornerstone to clinical judgment. It is much
faster and more accurate than any imaging study, and accurate clinical assessment is
necessary to determine what steps are required for further evaluation, to determine the
tempo of the workup, and most important, to identify those patients in critical condition
who need emergency intervention. Coma remains a classic problem in neurology, in
which intervention within minutes can often make the difference between life and death
for the patient. In this sense, the fourth edition of Plum and Posner’s Diagnosis of Stupor
and Coma does not differ from its predecessors in offering a straightforward approach
to diagnosis and management of these critically ill patients.
The authors owe a debt of gratitude to many colleagues who have helped us prepare
this edition of the book. Dr. Joe Fins generously contributed a section on ethics to
Chapter 8 that the other authors would not have otherwise been able to provide. Chap-
ters were reviewed at various stages of preparation by Drs. George Richerson, Michael
Ronthal, Jonathan Edlow, Richard Wolfe, Josef Parvizi, Matt Fink, Richard Lappin,
Steven Laureys, Marcus Yountz, Veronique van der Horst, Amy Amick, Nicholas Sil-
vestri, and John Whyte. These colleagues have helped us avoid innumerable missteps.
The remaining errors, however, are our own. Drs. Jonathan Kleefield and Linda Heier
have provided us with radiologic images and Dr. Jeffrey Joseph with pathological images.
The clarity of their vision has contributed to our own, and illuminates many of the ideas
in this book. We also thank Judy Lampron, who read the entire book correcting typos,
spelling errors (better than spellcheck), and awkward sentences. We owe our gratitude
to a series of patient editors at Oxford University Press who have worked with the authors
as we have prepared this edition. Included among these are Fiona Stevens, who worked
with us on restarting the project, and Craig Panner, who edited the final manuscript. Sid
Gilman, the series editor, has provided continuous support and encouragement.
Finally, we want to thank the members of our families, who have put up with our
intellectual reveries and physical absences as we have prepared the material in this
book. It has taken much more time than any of us had expected, but it has been a labor
of love.
Fred Plum, MD
Jerome B. Posner, MD
Clifford B. Saper, MD, PhD
Nicholas D. Schiff, MD
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Preface to the Fourth Edition