Clinical neurology, a Primer Peter Gates, Churchill Livingstone, Sydney, 2010, 403 pp., ISBN 9780729539357, RRP $AUD 94.95 (online $AUD 85.46).
General textbooks of neurology are usually first taken up by neurology registrars in training and are referred to repeatedly and often acquired in successive new editions throughout their career. For students and others interested in neurology, such books of at least a thousand pages are hardly a consideration, and they look to smaller more digestible books. Most of those are of little use.
Many years ago WB Matthews produced a little book, text only, called ‘Practical Neurology’. It had chapters on headache and arm pain, and some great wisdom was distilled into those succinct chapters. It was beautifully written. ‘‘The patient who says that the pin is not what he would call sharp doctor, anywhere on his body, is suffering from an ineradicably mistaken notion of the purpose of the examination.’’ Purpose is very much to the point in a textbook on neurology. That book was probably directed to the harried British general physician who had to deal with a lot of neurology and already knew a great deal. For the well trained modern neurologist it was more an entertainment, and can’t have been much use to a beginner.
What is needed for the beginner is what Peter Gates has provided, not that only beginners will benefit from this marvellous book. Dr. Gates is a very complete clinical neurologist, having been the only neurologist in Geelong for many years where he accumulated a vast clinical experience. He built up an excellent neuroscience department there at the same time as being a vivid contributor to the weekly clinical meetings at St. Vincent’s Hospital in Melbourne. He has been active in research and teaching in parallel with his busy clinical practice and was a frequent recipient of awards for his teaching. His excellent training and experience, his clear thinking about a case and his skills as a communicator and teacher are evident throughout this book.
The strength of this book is the perspective of experience brought to each topic, driven by clinical problem solving. Instead of bland lists that can be got from anywhere, the approach is to prioritize differential diagnosis, and encourage lateral thinking about the primary complaint. For instance, in the chapter on difficulty walking, the student is encouraged to be critical of the complaint of weakness in the legs, a complaint which needs to clarified. The ensuing diagram breaks up the complaint into weakness, unsteadiness and ‘not sure why’. This latter category lists Parkinson’s disease and gait apraxia as potential causes. When it comes to consideration in this chapter of the causes of spinal cord pathology a very succinct list is put forward first: cervical spondylytic myelopathy, thoracic cord compression, most often due to malignancy, and transverse myelitis. This is much more helpful than a table listing every known pathology affecting the spinal cord.
The early chapters do deal with neuroanatomy, but in a very selective way. Peter Gates has already published his rule of four of the brainstem, a pithy way for remembering brainstem and cranial nerve anatomy, and it is laid out clearly here. The diagrams in the book are very clear, and the many clinical photographs of examination technique are demonstrations by the author himself. Many of the clinical photographs of abnormalities are clearer than the standards in better known textbooks.
Following the neuroanatomy, the history and the detail of the examination comes a unique and important section entitled ‘After the history and examination, what next?’ This depends on the level of certainty of the diagnosis, or the differential diagnosis or whether, instead, you have no idea what is wrong with the patient, in which case he recommends that a particularly useful strategy is to start again. This section includes considerations of the urgency of the next step, particularly the ordering of tests, with the recommendation to consider the possible worst case scenario that might follow an important condition remaining untreated.
Essential aspects of diagnosis, investigation and treatment of many of the commoner conditions are all included in this book of less than 500 pages. Many chapters such as those on stroke and epilepsy do not necessarily differ a great deal from what is available elsewhere, but the three chapters ‘Common neck, arm and upper back problems’, ‘Back pain and common leg problems’ and ‘Abnormal movements and difficulty walking due to central nervous system problems’ (mentioned above) are especially good and are unique.
The references are numerous and carefully chosen. The McDonald criteria (2005 revision) for the diagnosis of MS are included in an appendix, of which there are nine. These cover epilepsy medications, the Mini Mental State Examination, a stroke thrombolysis protocol and stroke epidemiology. One of these appendices is a list of drugs for migraine, with doses. There is even a very useful chapter on consulting the medical literature.
Medical students, hospital medical officers and neurology registrars will benefit from having their own copy of this book and consulting it often and soon reading the whole of it. They will take to this book as it is clear and understandable and so obviously relevant to what they need. For anyone teaching students and resident staff there are many lessons in this book for how to approach the task. Some of the material will date, requiring subsequent editions, but the most important chapters will remain relevant for years and this is a book that will last.
Richard Gerraty
Epworth HealthCare, Department of Medicine, Monash University, Richmond, Vic 3121, Australia
E-mail address: richard.gerraty@monash.edu