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Autonomic failure. A textbook of clinical disorders of the autonomic nervous system, 4th edition
  1. Ray Chaudhuri

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    Edited by Christopher J Mathias and Sir Roger Bannister (Pp 562, £70.00). Published by Oxford University Press, Oxford, 2002. ISBN 0 19 262850 X

    The concept of autonomic disorders or dysfunction is an uncomfortable one for neurologists and as such remains poorly understood and managed within neurology. Part of this problem is because autonomic dysfunction spans several specialities of medicine, is largely based on good understanding of basic human physiology and anatomy, and interpretation of autonomic function testing is difficult. The 4th edition of the well known textbook of autonomic dysfunction, “Autonomic failure. A textbook of clinical disorders of the autonomic nervous system” aims to do this and much more. A huge collection of internationally renowned authorities contribute to this book.

    However, the thread of continuity is sometimes lost or repeated in this book. For example, it would be difficult to find a “user friendly” table/diagram of how to interpret blood pressure and heart rate changes following head up tilting. There is considerable repetition of information. Chapters on autonomic and neurohumoral control of cerebral circulation is followed in part II of the book by a chapter on autoregulation and autonomic control of cerebral circulation. Similarly, most neurologists would find chapters on cardiovascular autonomic regulation and control of blood pressure and circulation in man rather difficult to understand. It is also questionable how much of the information contained within “Clinical autonomic testing” (Part III) is clinically applicable. Most investigation related chapters such as chapters 21 and 24 appear to be largely research based and information in these and other chapters shifts between research studies and clinically established observations. However, chapters on postprandial hypotension, sleep dysfunction, and sudomotor function are outstanding, although the lack of mention of postprandial hypotension and its clinical significance in Parkinson’s disease is surprising.

    Part IV of the book concentrates on the relatively common autonomic syndrome of multiple system atrophy (MSA) and the exceedingly rare pure autonomic failure (Part IV). Bannister and Mathias contribute to a most useful and clinically relevant chapter on clinical features and evaluation of the primary chronic autonomic failure syndromes. A more detailed discussion on the rather controversial notion of Parkinson’s disease and autonomic failure and its differentiation from MSA with manifest dysautonomia is lacking and would have been useful. There is also confusion in terminology. According to the recent consensus committee definition, MSA is now subdivided in MSA-P and MSA-C subtypes, older terms such as striatonigral degeneration and olivopontocerebellar atrophy being obsolete. However, such terms keep on appearing both in the chapter by Bannister and Mathias and also in the chapter by S Daniel on neuropathology, which is nevertheless very informative. The following chapter by Matthews revisits much of the information already contained in previous sections of the book, such as a repetitive and confusing classification of autonomic dysfunction followed by a detailed neuropathological description of changes in ganglia and preganglionic neurones in dysautonomia. It seems this chapter is possibly better suited in the basic pathology introductory section of the book. The continuity and flow of this section is thus hampered by the order of chapters. Chapters detailing complex neuropathology, largely of research interest, follow chapters on clinically relevant tests of autonomic dysfunction. There is an excellent and clinically relevant chapter on management of postural hypotension, a clinical issue that perplexes a large number of neurologists and physicians for the care of the elderly. The latter chapter could have been enhanced by the inclusion of a flow chart outlining a step by step guide to treatment of postural hypotension, progressing from “first line treatment” to adjunctive treatment strategies. Furthermore, in the current climate of clinical governance and evidence based medicine, inclusion of evidence base for the use of the various treatment strategies mentioned in this chapter would have been useful. There are other omissions, such as the lack of mention of cardiac SPECT studies using MIBG in MSA and Parkinson’s disease, a technique that is increasingly being recognised as an important tool to help differentiate between early Parkinson’s disease and MSA.

    Part V of the book concentrates on peripheral autonomic neuropathies and there is an excellent chapter on diabetic autonomic failure. However, then a chapter is devoted to dopamine beta hydroxylase deficiency, which resembles a series of case reports of a condition few will encounter. A shorter, clinically relevant account of this condition could easily be accommodated under genetic causes of dysautonomia. In part VI, other important aspects of dysautonomia are discussed, notably syncope and ageing related changes. A simple diagram/table of interpretation of various haemodynamic changes following head-up tilting test would have been very useful for most neurologists who use this test clinically. In clinical practice, syncope is often confused with epileptic seizures, however, surprisingly little is mentioned about clinical differentiation and aspects of syncope and seizure. Once again, chapters on hypertension and cardiac failure overlap with previous ones and are of questionable clinical significance.

    The book is clearly written, although sometimes the chapters vary in preparation, practical value, and clarity. The quality of illustrations is high and there are few, if any, frank errors. In summary, this is an essential book for its target audience and would be useful in most medical libraries and to researchers working in the area of autonomic dysfunction.

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