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Inadequate funding has made collection development probably the most difficult and frustrating aspect of Nigerian university librarianship. The paper is a ten-year descriptive analysis of book acquisitions in Nigeria’s premiere medical library, considering trends, issues and challenges. The study reviewed book acquisition statistics reported in the library’s annual reports between 1999-2008. The comparative ten-year book acquisitions review, led to findings such as: irregular book collections due to inadequate funding, non-active acquisitions policy, dependence on uncensored gifts and donations irrespective of their ages. Doable recommendations as regards financial and acquisitions challenges are, commercialization of some library services, soliciting current book donations from friends of the library, repackaging topical (health) information for and library consultancy services.