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637 Postgrad Med J: first published as 10.1136/pgmj.24.278.637 on 1 December 1948. Downloaded from

THE DIFFERENTIAL DIAGNOSIS OF By PATRICK J. SWEENEY, M.D., M.R.C.P.I., M.R.C.P. Latelv First Assistant, Department of Medicine, Roval Victoria and West Hants Hospital, Bournemnozuth The difficulties in the diagnosis of the uncon- Case Report scious state are known to all. As an adequate A male, aged 45, admitted March 30, I948 with history is so often lacking, physical examination a history of severe headache for a week. must be exhaustive and the first essential is the Examination revealed a semicomatose . accurate assessment of the degree of unconscious- Pupils equal and light reactive, fundi normal, ness present. The term coma implies a state of muscle tone increased and reflexes generally unconsc;ousness from which the patient cannot increased. No neck rigidity or fascial weakness. be roused. Painful stimuli, e.g., firm pressure Bilateral extensor plantar response. over the. supraorbital foramen, have no effect. The Heart and lungs normal. Blood-pressure I20/70. corneal and pupillary reflexes, muscle tone, and Pulse 62. Temperature 980. the deep reflexes, are frequently abolished. Milder Lumbar puncture revealed a clear fluid under degrees of coma exist where, although the patient a pressure of 28o mm. Slight increase of protein, is unconscious, pupillary and corneal reflexes are and io white cells per cu. mm., mostly lympho- obtained and painful stimuli provoke a reaction. cytes. Two hours after the lumbar puncture, the indicates a state of partial loss of conscious- patient was sitting up in bed, quite rational, feeling ness where the response to external stimuli is well, but rather euphoric and unduly talkative. Protected by copyright. markedly diminished and is also characterized by During the next three days, his condition a tendency to resist interference and to . remained unchanged, but he complained of It is extremely important to record carefully the occasional headache and was subject to periods of degree of present at the initial drowsiness. No abnormal signs could be detected examination of the patient, in order to establish in the nervous system. a base line and follow the course of the condition. On April 5, I948, the lower limb reflexes were The slow development of cerebral compression found to be brisker on the left side, and the left following a , e.g. ruptured middle plantar response extensor. (The first localizing meningeal artery, illustrates the importance of signs.) this point. Particular must therefore be On April 7, 1948, he again became unconscious, paid to the pupils, fundi, muscle tone, deep with twitching and rigidity of all extremities. reflexes, plantar responses, pulse rate and tem- Both plantar responses were extensor. Blood sugar perature. Other points such as the odour of the and blood calcium normal. Repeat lumbar punc- breath, the type of breathing etc., are well known ture revealed a clear fluid under slightly increased to all, and will not be stressed here. pressure, with a marked increase of protein, and http://pmj.bmj.com/ The common causes of comatose, semi-coma- 29 white cells per cu. mm. The fundi remained tose and stuporose states will now be considered. normal. He was seen by a surgical colleague who sug- Trauma gested a diagnosis of right subdural haematoma. Unconsciousness following is short- Ventriculography was carried out with negative lived, but prolonged coma may follow cerebral result, and the patient died on April I0, 1948. contusion or laceration. from the nose Post mortem examination revealed a soft vas- or ears, or subconjunctival haemorrhage, may cular tumour in the right occipital lobe, which on on October 2, 2021 by guest. indicate a fractured skull and the need for radio- section proved to be a spongioblastoma of varied graphy. Lumbar puncture should be performed in pleomorphic structure. all cases, as the presence of blood in the cerebro- spinal fluid is often unsuspected. It should be remembered that an alcoholic Periods of drowsiness, stupor or coma from aroma is no guarantee that a cerebral injury has which recovery takes place with subsequent not occurred. Coma from a slowly developing relapse, and localizing pyramidal tract signs of subdural haematoma, the result of rupture of the type mentioned in this case, together with a cortical veins, is often difficult to differentiate from a slow pulse, are considered typicaf features of a tumour, especially as the original injury may. subdural haematoma. Cellular increase in the have been trivial and disregarded by the patient. cerebro-spinal fluid is not a feature, but is more 638 POST GRADUATE MEDICAL JOURNAL December I948 Postgrad Med J: first published as 10.1136/pgmj.24.278.637 on 1 December 1948. Downloaded from suggestive of cerebral abscess or tumour, as in the in order to exclude other medical or surgical case described causes of coma. To quote Walshe, 'alcoholic coma is diagnosed most safely by a process of Intoxications and Poisons exclusion.' Opium poisoning is seldom seen During the past year, 40 per cent. of the coma- nowadays. Its chief features are a cold, clammy tose admitted to the medical wards of this skin, a slow respiration rate, and pin-point pupils. hospital were suffering from, in the following In all cases of suspected poisoning, gastric lavage frequency, carbon monoxide, barbiturate and should be performed and the gastric contents aspirin poisoning. An indication, perhaps', of kept for analysis. is a rare cause present day conditions, when coupled with the of coma, and as a rule a preceding history of vomit- fact that alcoholic coma was not encountered. ing, abdominal colic, headache and constipation Carbon monoxide poisoning is usually obvious will be obtained. If suspected, the gums should from the history. It should be noted however, be exarmined for the well known blue line, the that the typical cherry-red colour of the face and blood for punctate basophilia and evidence of lips is not always present, and that even a mild anaemia, which may be haemolvtic in type, and degree of carbon monoxide poisoning may precipi- the urine analysed for lead. tate cardiac failure and pulmonary oedema with resultant coma, in a patient with pulmonary or Cerebral Vascular Lesions cardiac disease. A simple clinical test for carboxy- Coma resulting from cerebral haemorrhage, haemoglobin is to dilute-one drop of the patient's embolism or thrombosis is characterized by hemi- blood in a test tube of water, and compare with a plegia in the great majority of cases. Usually control from a normal person. A carmine tint will there is conjugate deviation of the head and eyes be evident if there is much carboxyhaemoglobin towards the side of the lesion, the paralysed cheek present. A diagnosis of barbiturate or aspirin flaps in and out with respiration, which is ster-Protected by copyright. poisoning is more difficult. Deep coma, sweating torous, and a positive Babinski sign is obtained on and extensor plantar responses are common to the hemiplegic side. Where lesser degrees of both. A raised temperature, cyanosis and pul- coma exist, a unilateral diminution or abolition monary oedema are typical findings in barbiturate of the is of value in distinguishing poisoning, as exemplified in the following case. apoplexy from other conditions. Where the pupils are unequal, it is always well to remember that Case Report the larger pupil is usually on the side of the A female aged 35 was admitted on October i9, haemorrhage. Syphilis must always be kept in I947. She was found unconscious in her flat with mind as a cause of cerebral thrombosis. Cerebral a bottle of nembutal capsules beside her. There embolism is suggested by the presence of heart were three capsules left out of a possible original disease such as mitral stenosis and auricular fibril- total of twenty-five. lation. Pontine haemorrhage results in homo- She was deeply comatose, i.e., ' corneal and lateral cranial nerve palsy and contralateral hemi- pupillary reflexes absent, deep reflexes absent, plegia, but all four limbs are soon paralysed as a limbs flaccid, no response to painful stimuli. rule. A high temperature and pin-point pupils http://pmj.bmj.com/ Bilateral extensor plantar responses. Cyanosed. further characterize this condition. In my experi- Moist skin. Breathing noisy and bubbly with ence, subarachnoid haemorrhage, the ' apoplexy moist sounds throughout both lungs, obscuring of young people,' has been the commonest the heart sounds. Blood pressure iIo0/90. Pulse individual disorder aniongst the cerebral vascular go. Temperature I00°. With large doses of cora- accidents admitted during the past year. The diag- mine and picrotoxin intravenously, the pupillary nosis is seldom difficult. Neck rigidity is the out- reflexes returned after three hours, but it was standing feature as a rule, but in some deeply three days before the patient became fully con- comatose patients, this is absent, and the diagnosis on October 2, 2021 by guest. scious and rational. is only apparent on lumbar puncture. Retinal .* * * haemorrhages, usually near the disc, vitreous and If no history is available, barbiturates can be subhyaloid haemorrhages, papilloedema, and 3rd detected in the urine and cerebrospinal fluid, using and 6th nerve palsies with resultant squint, are Millon's reagent. occasional features of a subarachnoid haemorrhage. Aspirin poisoning is characterized by evidence Frequently, bilateral extensor plantar responses of vomiting, profuse sweating, and deep breathing are obtained. The unne may-contain sugar and which may resemble the air hunger of diabetic albumin, and a rise of temperature up to ioo is coma. The ferrichloride test for salicvlates in the a common finding. urine is positive. Where alcoholic coma is sus- Hypertensive encephalopathy should-be thought pected, a careful physical examination is necessary of in the comatose patient with an extremely December I948 SWEENEY: Differential Diagnosis of Coma 639 Postgrad Med J: first published as 10.1136/pgmj.24.278.637 on 1 December 1948. Downloaded from high blood pressure, e.g., 250/I50. There may always either normal. or subnormal in uncom- be slight neck rigidity, but lumbar puncture plicated cases of either condition. It is well to reveals a clear fluid under high pressure. Changes remember that although a comatose patient is a in the fundi depend on whether the hypertension known diabetic, the diagnosis is not always one of has been long standing or not, and range from 'hvper- or hypo-glycaemia. slight arteriovenous kinking to papilloedema and retinal haemorrhages. Similarly, the urine may Case Report be normal, or contain albumin and casts. A male, aged 54, a known diabetic, was admitted on December 5, I947, in a deep coma. He mani- Case Report fested shallow rapid respirations, sweating, normal A male aged 50 years was admitted on October eyeball tension and bilateral extensor plantar res- 30, 1947. The history, obtained from an outside ponses. The urine contained a slight trace of source, was that for two weeks the patient had sugar, and no acetone. Blood sugar 85 mgm. per been complaining of headaches and had vomited cent. He had however, a temperature of ioo', and several times. On the day of admission, shortly a slightly stiff neck. Lumbar puncture revealed a before becoming unconscious, he had complained clear fluid with excess of cells (37 per cu. mm.- of sudden blindness. Examination revealed a mostly polymorphs), normal sugar content, normal heavily built man, semicomatose, pale skin and protein, chloride 700 mgm. per cent. Culture slight puffiness of the eyelids. A faintly uriniferous sterile. A chest X-ray revealed bilateral pul- smell from the breath was noted. The pupils monary tuberculosis, not apparent on clinical were equal and light reactive. There was slight examination. The patient died on December 13, bilateral papilloedema and evidence of arterio- I947, and at post-mortem the presence of tuber- venous kinking on examination of the fundi. culous meningitis was confirmed. Reflexes present and equal in upper and lower Protected by copyright. limbs. Doubtful bilateral extensor plantar res- There are rare cases of where ponses. Moderate neck rigidity. Lungs normal. sugar is absent from the urine, the explanation heart sounds normal. Blood-pressure 240/130. being that the patient was suddenly deprived of Pulse 65. Temperature 980. Lumbar* puncture carbohydrate and the fat metabolism became so revealed a clear fluid under a pressure of 300 mm. disordered that coma resulted. Similarly, there of water. The pressure was r-duced to 8o mm., are cases where the urine may contain much sugar venesection was performed, and a few hours after and albumin, but no acetone, and yet the breath admission'the patient was conscious, though com- may smell strongly of acetone. In such cases there plaining of blindness. Urine examination revealed is renal failure, casts will be found in the urine a dense cloud of albumin, numerous red blood anca the blood urea is raised. Hypoglycaemic coma cells, and moderate numbers of cellular casts. may be prolonged and fatal, as in a case described Blood urea 51 mgm. per cent. He rapidly im- by Winkler, where after an initial response to intra- proved, and in a further 48 hours his sight was venous , relapse occurred and the patient restored. On discharge from hospital his blood- died nine days later, without having regained con- pressure was 150/I00, but his blood urea was 42 sciousness. In this case, protamine zinc insulin http://pmj.bmj.com/ mgm. per cent. and his urine contained albumin- had been given by the practitioner, who mistakenly uria and casts, indicating permanent and severe diagnosed diabetic coma. Where no history of renal damage with a poor prognosis. insulin administration can be obtained, the pos- sibility of an islet celled tumour of th: pancreas Diabetic and Hypoglycaemic Coma must be kept in mjnd. It is surprising how often these two conditions are misdiagnosed in practice, thd more so when it Case Report is remembered that if in doubt, an intravenous A female aged 39 was admitted unconscious on on October 2, 2021 by guest. injection of glucose will .produce a dramatic March 23, 1948, with no history available. She recovery if the coma is due to hypoglycaemia, and was semicomatose-pupils equal and light re- will do no immediate harm if it is due to hyper- active, corneal reflexes present, fundi normal, glycaemia. A smell of acetone from the breath, a profuse sweating, bilateral extensor plantar res- dry skin, air hunger, soft eyeballs, flaccid muscles, ponses. depressed reflexes and flexor plantar responses Heart and lungs normal. Blood-pressure I20/70. characterize diabetic coma. The urine, obtained Lumbar puncture normal. Urine normal. Blood by catheterization, is loaded with sugar and ace- sugar 43 mgm. per cent. Blood urea 30 mgm. per tone. In hypoglycaemic coma, the eyeball tension cent. is normal, there is profuse sweating and the plantar A 5 per cent. dextrose drip was commexced, and responses are extensor. The temperature is two hours later she partially regained concious- 640 POST GRADUATE MEDICAL JOURNAL December 1948 Postgrad Med J: first published as 10.1136/pgmj.24.278.637 on 1 December 1948. Downloaded from ness, only to relapse again and become more and stupor are more characteristic deeply comatose than before. The dext.rose drip of encephalitis than deep coma. Lumbar puncture was continued and 20 cc. of 50 per cent. glucose reveals a clear fluid with excess cells, often lymph- given intravenously with no effect. The blood ocytes, and in contrast with pyogenic , sugar was now ioo mgm. per cent. the sugar content is normal or increased. Cerebral The patient remained unconscious for nine due to the malignant tertian parasite davs, during which time, aneurin, riboflavin, should be thought of in the case of a comatose nicotinic acid, and glucose were given in large hyperpyrexial patient who is known to have amounts, and her blood urea and blood sugar returned from an endemic area within a year. levels remained within normal limits. There were The parasites may be difficult to find in blood no localizing nervous signs and the fundi re- films, but the finding of intracellular melanin pig- mained normal. On regaining , she ment in the cells of the cerebrospinal fluid is diag- was aphasic, and did not recover the power of nostic. The difficulties in the diagnosis of coma speech until April 2I, 1948. Fasting blood sugars due to are illustrated by the following on the I5th, 20th, 23rd and 24th of April were 43, case. 40, 40 and 37 mgm. per cent. respectively. An exploratory laparotomy was advised to ascertain if Case Report an islet celled tumour of the pancreas was present, A male aged 2I was admitted on April 21, I948. but the patient took her own discharge against The only history available was that the patient advice. was quite well at breakfast, went upstairs, and (This patient *was readmitted to hospital on was found unconscious 20 minutes later. He July 14, 1948, comatose with a blood sugar of was restless, semicomatose, sweating profusely, 20 mgm. per cent. At operation on July i6, 1948, with rapid bubbly respirations. Temperature 102°. a benign adenoma of the tail of the pancreas was Pulse 104. Pupils equal and light reactive, rightProtected by copyright. successfully removed. The patient made an external rectus palsy, moderate neck rigidity, all uneventful recovery.) reflexes present and equal, lower limbs rather * * *I spastic, bilateral extensor plantar responses. Lungs Cerebral damage is well known to occur follow- -diffuse moist sounds. Heart-loud apical systo- ing prolonged hypoglycaemia, and presumably lic murmur, and systolic and diastolic murmurs this is the explanation of the aphasia, which took heard close to the sternum. No oedema or en- three weeks to clear up. gorgement of the neck veins. Lumbar puncture revealed a cloudy fluid with 470 polymorphs per Infections cu. mm. but no organisms. The patient died a few Coma due to meningitis, encephalitis, fulminat- hours after admission. ing septicaemias, malaria, etc. and as Post-mortem examination revealed mitral steno- a terminal phenomenon in the course of almost sis with large friable vegetations on the anterior any severe infection, is not infrequently seen. cusp of the valve. Infarcts present in the spleen and kidneys. The brain was congested, but showed Case Report no other naked eye abnormality. http://pmj.bmj.com/ A female aged 6o was admitted on March 22, :I * * I948. A history obtained from the relatives stated Multiple microscopic cerebral emboli undoubt- that the patient was well until the morning of edly occurred in this case, with resultant coma, March 2I,1948, when she complained of headache and excess polymorphs in the cerebro-spinal fluid. and refused her food. She retired to bed, and became delirious towards evening. Examination Miscellaneous Causes of Coma

revealed a pale, restless and resistive, semicoma- (i) Uraemia. A raised blood-pressure, albumin on October 2, 2021 by guest. tose patient. Temperature IoI°. Pulse ioo. and casts in the urine, and retinal changes, e.g. There was marked neck rigidity and a diffuse albuminuric retinitis, suggest uraemia. A careful purpuric eruption on the trunk and limbs. examination of the abdomen will sometimes dis- Lumbar puncture revealed an opaque fluid, close congenital cystic kidneys, or a distended and microscopy showed the presence of gram bladder. Rectal examination to ascertain if the negative intracellular diplococci. prostate is enlarged should never be omitted. The patient made a good recovery with com- (2) Cerebral tumour and cerebral abscess. Diag- bined penicillin and sulphamezathine therapy. nosis may be extremely difficult. Cerebral abscess is usually a of middle ear disease or This. case. illustrates. the rapidity of onset. of chronic pulmonary infectionsuch as bronchiectasis; coma in an acute fulminating meningococcal men- or empyema. If during the course of examination, ingitis. marked bilateral papilloedema is found, caution December I948 SWEENEY: Differential Diagnosis of Coma 641 Postgrad Med J: first published as 10.1136/pgmj.24.278.637 on 1 December 1948. Downloaded from should be observed with regard to lumbar punc- previous history of mental illness. A psychiatric ture. specialist kept her under observation for the next (3) Heart disease. It is frequontly forgotten that two days, and had no hesitation in diagnosing in congestive cardiac failure, the brain suffers of acute onset, with catatonic stupor. from venous engorgement. Coma from this cause is usually obvious. In Stokes-Adams syndrome, Vitamin Deficiency the duration of unconsciousness is brief as a rule, Chronic , carcinoma of the stomach *and the extremely slow or absent pulse is diag- or oesophagus, and diarrhoeal diseases such as nostic. ulcerative colitis, predispose to deficiency of thia- (4) Epilepsy. A history of 'grand mal ' is mine and nicotinic acid. A stuporose or semi- usually obtained, and the duration of the stage of comatose patient with pupillary'abnormalities or flaccid coma is brief. Evidence of tongue biting , evidence of peripheral neuritis, cog- and urinary incontinence should be looked for. ,wheel rigidity of the extremities, and grasping (5) Hysteria. The general attitude of the patient, and sucking reflexes, should suggest the possibility forced closure of the eyelids, normal pupillary of Wernicke's encephalopathy. Avery Jones and reflexes and normal deep reflexes with flexor Robinson have described an interesting case of plantar responses, usually leave the examiner in this kind, closely simulating diabetic coma, where no doubt as to the correct diagnosis. the diagnosis of Wernicke's encephalopathy was (6) Dementia praecox (schizophrenia). The confirmed post-mortem. They postulated injury sudden onset of a stuporose state can apparently to the hypothalamic area by a minute haemorrhage be the first manifestation of this disease. as the cause of the hyperglycaemia. Case Report Cerebral Emboli from Malignant Disease

Al female aged 26 was admitted in a stuporose Under the descriptive heading, coma carcino- Protected by copyright. condition on April 27, 1948. Her parents stated matosum, Purves-Stewart mentions the develop- that she had been in good health until two hours ment of coma in patients dying from visceral before admission, when they found her uncon- cancer with secondary malignant deposits. scious in her bedroom. Examination revealed a Occasionally the meninges become infiltrated with well-built female, colour normal, respirations malignant cells, and the latter can be found in the normnal, skin moist. There was diminished res- cerebrospinal fluid. ponse to painful stimuli. The jaw was kept tightly Coma must be a most unusual presenting feature clenched. Pupils equal and light reactive. Corneal of a carcinoma of the stomach, but such was the reflexes present. Fundi normal. She was generally case in the following instance. resistive, the arms and legs were held stiffly, and neck flexion was resented. Deep reflexes present Case Report and equal. Plantar responses flexor. Temperature A female aged 68 was admitted on December 980. Pulse 6o. Heart and lungs normal. Blood- IS, I947. Her landlady stated that for some weeks pressure I20/70. Urine examination normal. the patient had complained of indigestion and ' She remained in a stlIporose and resistive condition had only been able to eat sloppy' foods. She http://pmj.bmj.com/ for 48 hours, during which time repeated physical was found unconscious on the floor of her room examinations were made. The persistent spasm of a few hours prior to admission. the jaw was most noticeable. Lumbar puncture Examination revealed a wasted elderly woman revealed a clear fluid under normal pressure. with no obvious cyanosis or dyspnoea. Tempera- Laboratory examination revealed no abnormality. ture 970* Pulse 96. She was semicomatose, pupils Blood sugar normal. equal and light reactive, corneal reflexes present, On the afternoon of April 29, I948, she became arteriosclerotic changes in both fundi. Normal wide awake, sat up in bed, but did not speak or upper limb reflexes. Absent ankle jerks lower on October 2, 2021 by guest. answer questions. Shortly afterwards she was limbs. A right extensor plantar response was found out of bed and refused to get back. She obtained. Lungs, heart and abdomen normal. now answered questions, but gave confused replies, Blood-pressure iIO/65. and appeared to think she was attending lectures Thickened arteries palpable in both upper and clinical demonstrations at a medical school. limbs. Slight oedema of the ankles. She insisted on helping the ward sister to write Lumbar puncture revealed a clear fluid under out her reports. normal pressure, but microscopy revealed excess cells of a peculiar type (59 per cu. mm.). They It transpired that this girl was a first-year were large and granular, with one and sometimes medical student who had been studying very hard two eccentric nuclei. Some showed evidence of for some weeks prior to admission. There was no mitosis. Sternal puncture was performed, but 642 POST GRADUATE MEDICAL JOURNAL December 1948 Postgrad Med J: first published as 10.1136/pgmj.24.278.637 on 1 December 1948. Downloaded from revealed no abnormality. A blood-count was Hepatic coma is usually a terminal event in the normal except for a slight leucocytosis (i I,000 course of severe liver disease such as . white cells; polymorphs 88 per cent.). Exsanguination as a cause of coma is clinically The patient remained unconscious, neck rigidity obvious. developed, both plantar responses became BIBLIOGRAPHY extensor, and prior to her on December I9, AVERY JONES, F., and ROBINSON, V. C. (I947), Lancet, 2, 907. 1947, the cerebrospinal fluid pressure rose to 220 PURVES-STEWART, Sir James (I947), 'The Diagnosis of Nervous mm. and the temperature to I03°. Diseases.' p.153. WALSHE, F. M. R. (I947), 'Diseases of the Nervous System.' p.104. Post-mortem examination revealed a carcinoma WINKLER, J. L. (I948), Lancet, I, 215. of the stomach (papillary and trabecular on section) with secondary deposits in the adjacent lymph ACKNOWLEDGMENT glands and right suprarenal. There was carcino- I wish to thank Dr. T. Robson and Dr. J. H. matous infiltra-tion of the meninges over the Bentley for permission to publish details of these and cerebellum. cases.

BOOKS RECEIVED The Editorial Board acknowledge with thanks the receipt of the following volumes. A selection from these will be madefor review. Protected by copyright. ' Progress in Clinical Medicine.' Edited by ' Demonstrations of Physical Signs in Clinical Raymond Daley, M.A., M.D., M.R.C.P., and Surgery. Part III.' By Hamilton Bailey, F.R.C.S., Henry G. Miller, M.D., M.R.C.P., D.P.M. F.A.C.S., F.I.C.S., F.R.S.E. iith Edition. Pp. Pp. xi + 356. With 22 figures and I5 plates. io8. With many illustrations, some in colour. J. & A. Churchill, London. 1948. 21S. John Wright & Sons, Bristol. Simpkin Marshall, ' Osteo-Arthritis of the Hip-Joint.' By H. London. 1948. 8s. 6d. per part. Warren Crowe, D.M., B.Ch., M.R.C.S., L.R.C.P. ' Clinical Endocrinology.' By Laurence Martin, Pp. Viii + 70. With 24 plates. George Pulman & M.D., F.R.C.P., and Martin Hynes, M.D., Sons, Ltd. Distributed by Rolls House Publishing M.R.C.P. Pp. viii + 222. With 8 plates and 22 Co., Ltd., London. I948. 35s. 6d. text figures. J. & A. Churchill, London. I 948. 15s. 'Human Embryology and Morphology.' By 'Recent Advances in Respiratorv Tuberculosis.' Sir Arthur Keith. 6th Edition. Pp. xii + 690. With By Frederick Heaf, M.A., M.D., F.R.C.P. and 578 figures. Edward Arnold, London. 1948. 40S. N. Lloyd Rusby, M.A., D.M., F.R.C.P. 4th ' The National Health Service Act, 1946.' By Edition. Pp. vii + 290. With 5 plates and 7 text S. R. Speller, LI.B. Pp. xc ± 497. H. K. Lewis & figures. J. & A. Churchill, London. 1948. 2IS. Co., London. 1948. 42s. 'The Natural Development of the Child.' Bv http://pmj.bmj.com/ ' Critical Studies in .' By F. M. R. Agatha H. Bowley, Ph.D. 3rd Edition. Pp. xvi + Walshe, M.D., F.R.S. Pp. xV + 256. With i6 I90. With 84 photographic illustrations. E. & S. illustrations. E. & S. Livingstone, Edinburgh. Livingstone, Edinburgh. 1948. 8s. 6d. 1948. I P- 'Notes on Infant Feeding.' By G. -B. Fleming, ' Eden and Holland's Manual of Obstetrics.' By M.D., F.R.C.P., F.R.F.P.S. and Stanley Graham, Alan Brews, M.D., M.S., M.R.C.P., F.R.C.S., M.D., F.R.C.P.(Ed.), F.R.F.P.S. 3rd Edition. F.R.C.P.G. gth Edition. Pp. xii + 796. With Pp. 66. E. & S. Livingstone, Edinburgh. I948. 405 illustrations and 36 plates, 12 in colour. J. & A. 3s. on October 2, 2021 by guest. Churchill, London. 1948. 42S. 'A Surgeon's Guide to Local Anaesthesia.' By 'Obstetrics and Gynaecology.' By Beatrice M. C. E. Corlette, M.D., Ch.M., F.R.A.C.S. Pp. xi Willmott Dobbie, M.A., M.B., F.R.C.S., D.M.R.E. 355. With 200 illustrations. John Wright & Sons, Pp. xi + 358. With 22 illustrations. H. K. Lewis, Bristol. Simpkin Marshall (I94I), London. 1948. London. I948. 20S. 35S. 'The Medical Annual I948 (66th Issue).' Edited 'Viral and Rickettsial Infections of Man.' by Sir Henry Tidy, K.B.E., M.A., M.D., F.R.C.P. Edited by Thomas M. Rivers, M.D., Director of and A. Rendle Short, M.D., B.S., B.Sc., F.R.C.S. the Hospital, The Rockefeller Institute for Medical Pp. xii + 414. With 56 plates. John Wright & Research, New York. Pp. xvi + 587. With 77 Sons, Bristol. Simpkin Marshall, London, I948. illustrations, 6 being colour plates. J. B. Lippincott 22S. 6d. & Co. i948. 45S.