Brain, Vol. 124, No. 2, 444-445,
February 2001
© 2001 Oxford University Press
Book reviews |
INTRODUCTION TO CLINICAL NEUROLOGY.
2nd edition. By Douglas J. Gelb. 2000. Oxford: Butterworth-Heinemann. Price £22.50. Pp. 416. ISBN 0-7506-7202-1.
Department of Neurology, Gloucester Royal Hospital, Gloucester, UK
Neurology has long been perceived by medical students as being a difficult subject. As many neurologists enjoy teaching, it is unsurprising that quite a number have written short text books to help introduce students to neurology. Initially there were only a few such titles, e.g. an earlier Introduction to Clinical Neurology by Gordon Holmes, first published in 1946, or Neurology Simplified by David Lafia from 1960. However, there is now a profusion of such books aimed at the neurologically naive, many with titles including catchy phrases such as `essential. . . ', `lecture notes in. . . ', `key topics', `colour illustrated', or `made easy' to encourage the beginner. Indeed, I must declare a conflict of interest as an author of some such books.
In common with many of these introductory books, Dr Gelb's stated objective is to provide a systematic approach to neurological problems encountered in general medical practice, avoiding the esoteric and focusing on practically important distinctions. In addition, they aim `to inspire the readers to seek out patients with neurological problems and approach them not only with confidence, but with enthusiasm'.
The book is divided into four sections: `The basic approach', `Common diseases', `Common symptoms' and finally `Bookends' which deals with paediatric and geriatric neurology.
`The basic approach' introduces the idea of the localization of a neurological lesion as a game. The rules indicate that synthesis of symptoms and signs should aim to produce a unique localization, or series of possible localizations or demonstration of multiple lesions. This is followed by what is referred to as the `long version' of the game, working through the pathways involved in two examples in some detail. These are accompanied by line drawings of the pathways involved. The examples are followed by a description of an `abbreviated play' version which focuses on the levels of the nervous system at which the relevant pathways cross. Using this model they review the first two examples and consider a further five.
The discussion of their first example, a patient with weakness of right little finger abduction and sensory loss on the right little finger, was unhelpful in two ways. First, it is a localization most experienced neurologists (and hopefully many students) would make by pattern recognition, another common diagnostic approach, as almost always resulting from an ulnar nerve lesion. Secondly, their analysis in `long play' puts the lesion in the frontoparietal cortex or somewhere between the C8/T1 nerve roots and the ulnar nerve, an analysis that suggests there should be other signs. In their `abbreviated play' they suggest MRI brain as appropriate investigation for what is most likely to be an ulnar lesion and suggest the lesion `could not possibly be in the cervical spine', despite syringomyelia being a rare possibility. Their second example, a brainstem lesion with crossed sensory loss, is better. The remaining examples are mixed with some schematic neuroanatomical drawings illustrating the visual system, language, the pupillary light reflexes and the sympathetic supply to the pupil. As the neuroanatomy is introduced to illustrate the cases, it is not introduced systematically and seems to assume a reasonable level of anatomical knowledge. At the end of the section there are 11 rules or shortcuts for `speed play'. Most are simple and straightforward, e.g. that aphasia indicates a dominant hemisphere lesion. Some are misleading, e.g. suggesting that dysarthria in the absence of dysphasia indicates a subcortical, brainstem or cerebellar lesion, excluding the possibility of a lower motor neurone, neuromuscular junction or muscular cause.
The neurological examination section goes through a description of the conventional examination with relatively few illustrations (six line drawings). The author adds a commentary of his own views on the value of certain parts of examination in italics. There is a brief section discussing the significance of some of the findings with some aspects, e.g. the features of the 3rd, 4th and 6th cranial nerves, discussed elsewhere. I think this separation of technique examination from potential findings makes it harder for the student to develop effective examination skills. There are a few errors, e.g. finger extension is said to be innervated by C8, rather than recognizing its major contribution is from C7.
Reading this account of examination, the beginner would not appreciate that some physical signs are `harder', that is to say more significant, than others and that any interpretation of the examination needs to take this into account. There is no mention of the fact that some examination findings may not be organically determined or any discussion of features that might suggest this.
There is then a brief chapter `What's the lesion?' by Dr Albers and Dr Gelb. This chapter links clinical conditions with the likely underlying pathological process on the basis of localization (focal, multifocal or diffuse), time course (acute, subacute or chronic) and temporal profile (improving, static or progressive). This approach is well illustrated by 11 clinical vignettes.
The next section, `Common diseases', has chapters based largely on disease type rather than localization, including stroke, seizures, neuromuscular disorders, dementing illnesses, movement disorders, sleep disorders and multifocal CNS disorders. This approach is based on the assumption that the diagnosis has already been made, though it is not clear how the beginner would do this. For example, there is little about the symptoms which a patient with Parkinson's disease or myasthenia might present with. There is no discussion of the clinical classification of stroke or of the differential diagnosis of stroke. This section is sparsely illustrated (two figures in 120 pages) and there is a single table listing anticonvulsant dosages and adverse effects. There are a number of clinical vignettes at the start of each chapter, with a discussion of these at the end and I felt these often gave more insight into the clinical presentations of the conditions than the text of the chapters. Some cases have a strong North American bias, with the stroke section discussing thrombolysis as a standard treatment. Others are controversial, e.g. the use of anticoagulation acutely in a patient with a stroke and atrial fibrillation.
The next section deals with common symptoms: acute mental changes, headache, visual symptoms, dizziness and disequilibrium, back and neck pain and incontinence. Again, these were accompanied by clinical cases which take up almost half the space in some chapters, though there were only two cases for headache. There are some limitations in these sections. For example, in the section on acute mental changes there is an emphasis on diagnosis and no general advice as to how to manage a patient with delirium. There is mention of spinal cord compression in relation to back pain but no specific description of the clinical picture or its management and it does not appear in the index. There are no illustrations, a notable deficiency for example, when trying to understand eye movements, or how to perform a Hallpike's manoeuvre.
The `Bookends' section briefly deals with paediatric and geriatric neurology and highlights differences from the rest of adult neurology. Clinical vignettes are a large part of these sections.
In any short text, one of the biggest problems is what to leave out. There are two omissions that detract from the book. First, as most neurological diagnoses are made primarily on the basis of the clinical history, I was surprised that there is no section devoted to taking a history. Secondly, some patients seen in the neurology department do not have organic neurological problems; some recognition of this and discussion of the diagnosis and management of functional neurological problems and somatization would be useful.
All introductory or simplified neurology books have a particular approach to try to help their readers. This book tries to help the student to understand how a neurologist solves problems by emphasizing localization. I felt this did not work very well and was done at the expense of other tools for diagnosis, particularly history-taking and pattern recognition. Having emphasized the role of localization, the author might have highlighted the relevance of this approach by using a localization-based classification of neurological problems, rather than using one based primarily on disease process.
The other aid was the use of clinical vignettes, which I thought was a useful learning aid in many of the sections. Some sections, especially those where diagnosis depends on pattern recognition, such as headache, would benefit from more cases.
The paucity of illustrations in this age of multimedia and easy illustration is not acceptable. There are more illustrations in the 1946 version of the same title by Gordon Holmes.
Overall, despite Dr Gelb's attempt to highlight the fun element in the game of localization, I felt that many of the other contemporary introductory texts provide a more effective (and cheaper) introduction to clinical neurology.
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||