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“All we really understand about neurological disease we have learned from pathological studies.”
Self evidently not a perfect truth, but it is a fair approximation, particularly if “understand” is properly weighted. Take multiple sclerosis as a random example. We have been taught a great deal about the course and dynamics of the disease—for example, by new imaging techniques, but MRI has come closest to contributing to our understanding of the disorder when married to pathological studies, or when used as a surrogate marker of pathology. The huge power of the new genetics has now set its sights on multiple sclerosis, and although proceeding apace and well in to the genome screen approach, it too has yet to contribute major insights to our understanding of multiple sclerosis. Animal models, even the aged EAE, can only offer suggestions which live or die according to correlative studies of multiple sclerosis tissue or patients. And my own area of interest, the cell biology of oligodendrocytes studied (mostly) by cell culture, is no better or worse than these other tools: it can make suggestions which must be tested by direct examination of tissue—by pathology.
It follows that good neurology must depend on a decent grounding in pathology, and a neurological training which fails to include and indeed emphasise pathology is a poor and incomplete one. Calman’s prescription for postgraduate education presents an opportunity formally to ensure that training schemes do not permit the possibility of such deficiency. So would the sixth edition ofGreenfield’s Neuropathology feature on an idealised neurological curricular reading list? It could not fail to.
To continue with the above example, the account of demyelinating disease—and with what better subject to start? Considering Greenfield’s own contributions to the pathology of multiple sclerosis, the most conspicuous at present is his definitive study of axon loss in multiple sclerosis, which surely is one of the finest wheels to be reinvented. This must be as good an account as any available. It is (not withstanding the book’s two volumes and 2200+ pages) not overly long—86 pages, but strikingly well structured, generously (and often beautifully) illustrated with 95 figures, the great majority photomicrographs and many in colour, and closely and carefully argued, with over 500 references. Prineas and McDonald have combined and distilled their unique and enormous experience to provide a scholarly, authoritative, and yet wholly readable review of multiple sclerosis and the associated demyelinating diseases, a benchmark account against which current and future efforts must be measured.
How to move on, to provide anything remotely resembling a useful review of the remaining 25 chapters? Several merit particular attention. “Prion diseases” (DeArmond and Prusiner) and “tumours of the nervous system” (Lantos, Vanden Berg, and Kleihard) are both new to Greenfield’s book. Both represent topics whose biology and pathology have changed at a breathtaking pace over the past five years, a sure challenge to any textbook harbouring ambitions of definity. Typically, both rise to the call with apparent ease. The chapter on prion disease is only 35 pages long, but this is nevertheless a comprehensive and fine account of an extraordinary area of the human neurology and neuropathology. There are excellent descriptions not only of conventional dementing prionopathies, but also of rarer, more recently recognised entities such as fatal familial insomnia. The biological controversies and molecular dissection of the disease are amply covered, and space is even found for speculation concerning the possible involvement of prions, in yet another evasive and tantalising disease, inclusion body myositis.
The tumour chapter—an all embracing 200 pages with more than 3000 references (I lost count)—is again quite masterly. The bread and butter tumours are capably described, and there are instructive and useful accounts of other important areas—familial tumours, metastatic disease, etc. Again, the narrative is as contemporary as a large text can be, and more up to date than most, with succinct descriptions of the NF siblings neurofibromin and merlin, and of their biology, as far as is known. Surprisingly, in this generous chapter, paraneoplasia is perhaps a little brief.
It would be unforgivable also to omit mention of the chapter on peripheral neuropathy (Thomas, Landon, and King). Just 100 pages long, this yet again is a joy to read. The first fifth is devoted exclusively to a description of the normal peripheral nerve, an outstanding account. The whole chapter is (predictably) beautifully illustrated, with authority spread deep and thick and even across the whole landscape of peripheral nerve disease, from new immunological concepts in relation to inflammatory neuropathies, to the molecular genetic advances in inherited nerve disease.
So, it is not easy to criticise. I managed to amass a perfectly miserable haul of just one typo (though quite a howler—BAL forBALO—in a bold, italicised, large font header). The editing is lightly but highly effectively administered, and there are very few outright omissions. I could find no account of Hashimoto’s encephalopathy, which is a shame; I suspect many years of further use might fail to add appreciably to this one omission.
This is such a good book. Do buy one. It is well worth the investment, and will stand by you and repay you all the days of your working life.
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