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The Neuropathology of Dementia
  1. JOHN XUEREB

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    The Neuropathology of Dementia. Edited by margaret m esiri and james h morris.(Pp 440; £75.00.) Published by Cambridge University Press, Cambridge. 1997. ISBN 0-521-43311-8.

    This distinguished pair of Oxford neuropathologists offer a new book to the “pathologist faced with the task of determining the cause of dementia in cases requiring post-mortem diagnosis”. They are credited with editorship; actually, they have written 11 chapters and two appendices, among them those chapters which deal with the pathological processes which account for 90% of adult dementia (Alzheimer’s disease, vascular disease, and Lewy body disease). For the remaining eight chapters and appendix, Professor Esiri and Dr Morris recruited acknowledged experts.

    After an introductory chapter on dementia, which describes the clinical syndrome and describes its neuroanatomical basis, there are two chapters in which Esiri and Morris define the practical approach to the pathological diagnosis of dementia. The first of these chapters describes (and illustrates diagrammatically) the neuroanatomical structures which are particularly pertinent to cases of dementia. The diagrams of neural connectivity in the hippocampus and neocortex may daunt the general pathologist, but the chapter provides a useful summary of pathological processes which affect each anatomical region of the brain; that is to say, it offers a regional approach to the differential diagnosis of dementia. The second of these chapters gives instruction on the conduct of the postmortem in a case of dementia, details the observations which should be made on the unfixed brain at the time of postmortem, and on the fixed brain, and provides a scheme for the selection of tissue blocks and histological stains.

    The rest of the book is composed of chapters which are dedicated to individual causes of dementia, starting with the commonest diseases: Alzheimer’s disease, vascular disease, and Lewy body disease. The very numerous rare causes of dementia are all discussed in subsequent chapters, which include adequately comprehensive and uptodate accounts of aetiology and pathogenic mechanisms, but manage to retain the practical perspective; a mark of successful editorship. I should emphasise that this book is not simply a practical manual although it largely succeeds in that respect. It succeeds also in taking a common sense approach to issues which are controversial among neuropathologists. The general pathologist who turns to this book will receive sound advice on such matters as the pathological diagnostic criteria of Alzheimer’s disease and its distinction from age related changes, on the relation of head injury to the pathogenesis of Alzheimer’s disease, and on the range of clinical and pathological phenotypes which are included variably under the eponymous label of Pick’s disease.

    Yet in some instances, the editors do not take the generalist’s side. Surely, it is unreasonable to recommend special neurohistological techniques like Cajal’s gold chloride, the silver impregnations of Bielschowsky and Cross, and Holzer’s method, when the information which these preparations provide can be obtained with the immunoperoxidase techniques which are in everyday use in the general histopathology laboratory. Antibodies against βA4-peptide, paired helical filament related tau epitopes, ubiquitin, glial fibrillary acidic protein, and neurofilament protein are commercially available, and the technique is standard, of reproducible quality, and may be automated. Diffuse and neuritic forms of the senile plaque, neurofibrillary (tangle) degeneration, Pick bodies and Pick cells, cortical Lewy bodies, the cortical neuronal inclusions of motor neuron disease, and astrocytic gliosis are all easily demonstrated with this panel of antibodies. There is merit in recommending the combined Luxol fast blue and cresyl violet preparation (which stains myelin sheaths blue and neuronal perikarya purple, when properly done) because it offers considerable help with anatomical localisation of individual nuclei and fibre tracts in sections of basal ganglia and brain stem. However, plaques of demyelination are just as easily diagnosed on haematoxylin and eosin stained sections, so that the pathologist who is confident of anatomical landmarks can dispense with traditional myelin stains too.

    I am disappointed with the index. Look up ubiquitin and none of the page numbers to which you are referred will tell you about its value in identifying cortical Lewy bodies. Look up tau and you will be referred to pages about neurofibrillary tangles but not to the sections on Pick bodies or the tangle-like inclusions of corticobasal degeneration. There are other examples.

    The reader is also let down with some of the illustrations. It is gratifying to find a substantial neuropathology textbook selling for significantly less than £100 but a book which is intended to assist someone peering down a microscope at coloured histological preparations should have many more colour photographs. Surely, modern publishing technology can produce colour illustrations and still keep to moderate prices. Also there are several errors. Two examples will make the point: the two photographs in figure 3.12 (a) and (b) are wrongly positioned in relation to the legend, and the photographs in figure 5.10 are clearly from luxol fast blue preparations (indeed it says so in the legend) but the stain/magnification label says H&E.

    One other niggle is the tendency, in a few chapters, for the authors to overreference the texts. As the style of referencing is that of authors and year of publication, rather than numerical superscript, overreferencing can make a chapter unpleasant to read and impossible to scan for particular information (such as a key word from the index). David Mann’s chapter on Down’s syndrome is a particular example of the way in which references pepper the text like an obstacle course.

    The remarks in the last four paragraphs do not diminish significantly my admiration for this book. I concur with the view of Sir Bernard Tomlinson who remarks, in the Forward, that “the principal authors have, through their own clear accounts, their perceptive insight into pathologists’ needs, ....produced a book which will be a most welcome addition, and perhaps a treasure, in many laboratories, clinical libraries and personal collections”. I am very pleased to have it and I recommend its purchase.

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