Brain, Vol. 123, No. 3, 653-654,
March 2000
© 2000 Oxford University Press
Book reviews |
NEUROLOGY IN TROPICS.
.
University Hospital of Birmingham, NHS Trust, Queen Elizabeth Hospital, Birmingham, UK
This is an interesting and, at the same time, an irritating book. Its purpose is to provide a work of reference, and it is aimed at neurologists world-wide who may have to deal with illness in patients who have travelled from the tropics, postgraduates in neurology, neurologists in the tropics and general physicians in those regions. The format is to group the 56 chapters into seven sections: nutritional disorders and neurotoxicology; CNS infections; neuromuscular diseases; cerebrovascular diseases; epilepsy; demyelination and degeneration; and a miscellaneous group which includes chapters on history, epidemiology, future developments and public health. There are 94 contributors, 66 of whom are from the Indian sub-continent. Although there is a bias towards India, the contributions from elsewhere are sufficient to provide a truly global perspective of neurology. Inevitably, with such a large number of contributors, the quality of the chapters varies.
For me, and I suspect for most Western readers, the main interest of the book lies in the descriptions of those conditions which we do not see in our everyday practice. An overview of neurotoxins in the tropics (Chapter 3) provides a miniature of the strengths and weaknesses of the whole publication, yet holds the attention overall. In the attempt to be encyclopaedic, descriptions of conditions such as lathyrism and mercury poisoning are mentioned briefly, while better, whole chapters on these subjects appear later. The assertion that Gulf War syndrome is due to the toxic effects of Permethrin, DEET and Pyridostigmine bromide has not been proved. The description of marine neurotoxins by Watters and Cannard is masterly—fortunately we are unlikely to encounter patients suffering from these in Britain. A chapter devoted to Minamata disease is perhaps anachronistic; as a description of methyl mercury poisoning it serves its purpose. The chapters on lathyrism, fluorosis, konzo and organophosphorus poisoning are comprehensive and compare favourably with those of similar publications. Tetanus is rightly given a chapter of its own, which includes a good résumé of the clinical features and treatment, but is marred by imperfect editing—reference 24 does not appear in the text. Botulism is confined to a meagre paragraph in the neuroepidemiology section.
The section which describes CNS infections is, perhaps not surprisingly, the strongest section of the book. The HIV chapter by Katabira is from Africa and relates a different perspective of AIDS from that seen in the West. The section which deals with management realistically observes that economic factors make it impossible to use anti-viral agents in the tropics, yet complete therapeutic nihilism can be countered by well thought-out simple management strategies which include counselling. The chapter on HTLV-1 infection by Trelles is disappointing: there is no discussion of differential diagnosis, or relationship, if any, to multiple sclerosis. Acute haemorrhagic conjunctivitis, herpes simplex encephalitis (HSE) and Japanese encephalitis and rabies are adequately described. The authors debate the pros and cons of brain biopsy in HSE but do not give clear recommendations. I doubt whether anyone would advocate brain biopsy for HSE nowadays; whether the pathology of herpes simplex encephalitis warrants a separate chapter is arguable. The chapter on poliomyelitis is disappointingly brief and the description of the clinical details of paralytic polio is cursory in the extreme—much more space is given to the post-polio syndrome. I have not seen a case of subacute sclerosing panencephalitis (SSPE) for many years as the incidence in Europe and America has fallen so dramatically with the success of measles immunization programmes: it was timely to be reminded of SSPE in the excellent chapter by Prabhaker and Mathen. Neurocysticercosis by Sotelo and del Brutto is comprehensive, and hydatid disease by Kak and Mathuriya is particularly well illustrated. Other infections that warrant separate chapters are malaria, schistosomiasis, neuroangiostrongyliasis, neurofilariasis, African trypanosomiasis, neurobrucellosis, pyogenic meningitis and CNS tuberculosis. Each is adequate and largely repeats what the individual authors have written elsewhere. Whether the pathology of CNS tuberculosis justifies its own chapter is debatable; the imaging of CNS TB certainly does and is well done here.
The neuromuscular diseases section is a hotchpotch. Tropical pyomyositis by Radhakrishnan and Thomas is comprehensive and well referenced. The classification of the tropical neuropathies is curious—are harvesting neuropathy and diamond-sorters neuropathy any different from any other form of neuropathy due to entrapment or pressure? Why include lathyrism when the authors acknowledge that peripheral neuropathy has not been reported in this condition in humans, only in laboratory monkeys?
The cerebrovascular disease section includes chapters on Takayasu arteritis and Moya Moya disease. The chapter which provides an overview of strokes in the tropics rightly points out the difficulties of obtaining epidemiological data on stroke in developing countries then rather uncritically suggests that anticoagulants should be given for progressing strokes and may be combined with dipyridamole or ticlopidine. Surely such a subject warrants a more critical appraisal, if for no other reason than the cost of such drugs balanced against their effectiveness (or lack of) in a region of economic deprivation. There are chapters dealing with strokes in the young and with cerebral venous thrombosis.
Why chapters on `Infantile tremor syndrome' (which seems to be peculiar to the Northern and North Western Indian states and is of unknown aetiology) and on `Hot water epilepsy' (which is limited to the South of India and is also of unknown aetiology but from the descriptions given could easily qualify as a pseudoseizure) should be included in a textbook for a global audience is not clear. The sections on epilepsy do emphasize the higher incidence of symptomatic epilepsies encountered in such regions but give no advice on the management of idiopathic epilepsy. The neuro- epidemiology chapter is disappointing, and is really a misnomer because it is only a summary of the diseases described in the preceding chapters with the most cursory attempt at indicating their frequency, prevalence or distribution.
The feature of this book which I found most irritating was its failure to reach the aims which the editors set. To a large extent, the blame for this must be the editors'. There is too much repetition—exemplified by the first two chapters, which describe protein energy malnutrition and nutritional rehabilitation. Lathyrism is described in Chapter 3 (Neurotoxins) and Chapter 6 (Lathyrism). The English is frequently eccentric and the quality of the illustrations varies, many are excellent, but some are barely discernible (Figs 39.2 and 39.3).
Would I buy this book or recommend it as a reference text to a postgraduate trainee from the tropics? The answer is a reluctant `No'. There are better and more comprehensive textbooks available. Unfortunately, this volume tries to be all things to all men, and fails to cover the common and more mundane subjects as extensively as it should. Despite this criticism, I hope that the editors will be encouraged to try again, next time reducing the number of contributors and wielding the red pen with much greater vigour.
Notes
Edited by J. S. Chopra and I. M. S. Sawhney.
1999. Pp. 692. New Delhi: B. I. Churchill Livingstone Pvt Ltd.
Price not stated. ISBN 81-7042-121-7.
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