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The initial chapter of this monograph deals with the pathological physiology of the signs and symptoms of coma. The basic studies are directed at the state of consciousness, pattern of breathing, size and reaction of pupils, eye movements, and skeletal muscle responses, and the value of the electroencephalogram in differentiation of comatose states is emphasized. In the section on supratentorial lesions causing coma, the authors distinguish three patterns of shift: cingulate herniation, central transtentorial herniation (of the diencephalon and midbrain), and uncal herniation. The diagrams using EEG, pupillary changes, eye movements with head turning and caloric stimulation, and motor responses are particularly graphic. The concept of rostral-caudal deterioration is well illustrated. Specific supratentorial lesions ( extracerebral and intracerebral) are mentioned and the mechanism of action pointed out.
A shorter chapter deals with subtentorial lesions causing coma, including vascular occlusions, hemorrhages, and neoplasms. The most elaborate chapter covers metabolic
Sugar O. The Diagnosis of Stupor and Coma. JAMA. 1967;199(4):284-285. doi:10.1001/jama.1967.03120040094037