Brain, Vol. 124, No. 2, 447-448,
February 2001
© 2001 Oxford University Press
Book reviews |
MEDICAL NEUROSCIENCES. AN APPROACH TO ANATOMY, PATHOLOGY AND PHYSIOLOGY BY SYSTEMS AND LEVELS.
Fourth edition. By Eduardo Benarroch, Barbara Westmoreland, Jasper Daube, Thomas Reagan and Burton Sandok. 1999. Philadelphia: Lippincott Williams & Wilkins. Price $39.95. Pp. 631. ISBN 0-78-171426-5.
Institute of Neurological Sciences, Southern General Hospital, Glasgow, UK
For one long since cast adrift on the sea of clinical neurology, a text that offers to review and update knowledge of basic neuroscience as a framework for the evaluation of clinical problems is most welcome. The fourth edition of Medical Neurosciences is, like its predecessors, the product of academic neurologists based at the Mayo Clinic and Mayo Foundation. The authors in the introduction outline the importance of integrated neuroscience for the clinician, emphasizing that the prerequisite for diagnosis and management is an understanding of the anatomy, physiology and pathophysiology of disease states. To this end they address the importance of neurological localization and the various pathological mechanisms that result in disease. Neurology is perhaps unique amongst clinical specialties in its dependence on such information for its good practice.
The book is divided into three sections, the first dealing generally in what is referred to as a `survey of the neurosciences', this section covering neuroembryology, anatomical localization, neurocytology and pathological reactions of the nervous system and neurophysiology (particularly in respect of transient disorders). The second section deals with what the authors refer to as `longitudinal systems' by which they mean integrated anatomical and physiological pathways such as the motor, vascular and neurochemical systems. The final section deals with `horizontal levels', addressing the peripheral nervous system, spinal, posterior fossa and supratentorial levels. This approach to longitudinal systems and horizontal levels is unique to this text and certainly one that has been tried and tested in the three preceding editions. The text follows the traditional neurological approach to disease in terms of `where is the lesion' and `what is it'?
Each chapter in the three sections is set out in a standard format of learning objectives, introduction, overview, clinical examination, clinical problems and additional reading. I find that this compartmentalization does not necessarily make for easy reading; in particular, the text is not immediately accessible for dealing with specific clinical problems and, whilst the anatomical detail and both anatomical and physiological illustrations are of high quality and well worth incorporating into one's teaching material, there is a distinct lack of modern imaging and little feel of how to develop an investigative pathway for specific clinical problems.
Despite these criticisms, the text is indeed extremely detailed and does provide an important framework for clinical practice. I found the chapter on the diagnosis of transient disorders and their neurophysiology particularly informative and well written, though the overview addressing cell membrane function was too mathematically detailed. Nonetheless, the text gave a clear, comprehensive account of mechanisms of excitability, propagation and synaptic transmission. The clinical correlates in this section were also valuable in helping to understand the mechanisms underpinning channelopathies, seizures and the physiological consequences of demyelination. The clinical problems at the end of this section also helped ensure an understanding of the text and, as in all chapters, were accompanied by answers at the end of the book. The sections on internal regulation or homeostasis and the consciousness system also made important reading in terms of clinical value. The section on the vascular system contains some helpful illustrations, particularly in relation to understanding cerebral metabolism. However, here I found the clinical correlates to be simplistic and very much of an undergraduate level.
Moving on to the sections on `horizontal levels', I particularly enjoyed the brief chapter on nerve and muscle which, as a non-specialist, was informative and of clinical value, especially the account of electrophysiology and the indications and interpretation of nerve and muscle biopsy. Again, at the end of this section, I found the clinical problems to be somewhat over-simplistic.
Clearly, any book running to its fourth edition is meeting a need, but the difficulty that I had in reviewing this book was one of not knowing precisely who the content is targeted at. The authors, in their preface, indicate that it is for new students (presumably undergraduates) as well as more experienced students (presumably clinical practitioners). The book, however, falls mid-way between the two in that, whilst I found it did update me in certain aspects of pathology and physiology that were new or no longer at my fingertips, the clinical correlations and problems presented at the end of each section were not at a level that a practising clinician would find demanding. I had hoped, when picking up this book, to be able to fill gaps in my own knowledge on the molecular mechanism of disease and the new genetics; unfortunately, in this respect, I was left disappointed. Whilst accepting the unique manner in which this book presents itself with respect to systems and levels, I did find the text inaccessible and felt that compartmentalizing neurological disease at specific levels was restrictive in its artificiality.
Would I recommend this book? I think yes, particularly for the clarity of its anatomical illustrations and the simple and didactic way in which it presents an update of the anatomy, physiology and pathology important for clinical practice. The book would have to be used in conjunction with a standard clinical text and I suspect would be `dipped into' for reference, rather than read in its entirety. Perhaps for future editions, clinical correlates and presentations could be better integrated into the text rather than left starkly at the conclusion of sections. Also, any text on medical neurosciences should, I believe, if it is to be of value to people like me, address the growth areas of neurology with relation to genetics, pharmacology and immunology, all of which are sadly deficient here. Finally, there is a paucity of imaging, particularly in relation to the neuroscientific basis of functional imaging, PET, SPECT and functional MR imaging.
In conclusion, for the anatomy and physiology, this book is of value but, if one is looking for a broader update on medical neurosciences, I am afraid the reader will be disappointed.
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