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Clinical cases in neurology
  1. M Donaghy

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    Edited by A H V Schapira and L P Rowland (pp 261, £32.50). Butterworth Heinmann, Oxford 2001. ISBN 0 7506 4304 8

    Any review of a compendium of case histories must resemble that of a crime novel. How much do you say so as to whet the appetite without inducing such a degree of satiation as to make the meal not worth eating? Different people learn their neurology in different ways, and only some will wish to tease themselves by solving illustrative clinical case histories. This volume contains 29 cases covering the breadth of neurology, to which a total of 27 neurologists have contributed variously. The editors' choice of the range of clinical problems cannot be faulted. The test of such a volume is to expect to solve those cases which consider one's own subspecialty area, and to judge whether the cases are presented fairly, while being difficult enough to induce a frisson of uncertainty, and then to decide whether you agree with the range and balance of the ensuing discussion. Of course one's better registrars should be able to get them all, whatever the subspecialty.

    Compendiums of case histories should focus on the clinical method rather than merely acting as a vehicle for science, which can be reached more systemically in textbooks. A few of the cases in this volume slightly miss this clinical target. For instance an obvious case of hemiplegic migraine described in one and a half pages is followed by eight pages of discussion which do not illuminate the clinical discussion of differential diagnosis, but are largely concerned with molecular genetics and functional imaging. By way of contrast, another case of ataxia manages to discuss the different spinocerebellar ataxia mutations in terms of their clinical phenotype; indeed one can estimate how up to date is the text by the number of SCA mutations describable at that point in time (this book coincides with SCA-11). A few of the cases are not really diagnostic challenges. For instance the text of a case of spontaneous low pressure headache contains the answer that radiological contrast was noted to seep from nerve root sleeves; wouldn't it have been better simply to show the relevant CT myelogram and leave the reader to inspect this in forming their own diagnostic opinion? And the first sentence of the discussion of the case of brain tumour tells us that it was an oligodendroglioma. I am always nonplussed to the point of irritation by those tacticians who withhold crucial information when they present case histories. That of a young man with a movement disorder and accompanying speech disturbance contains no mention of any search for Keiser-Fleischer rings, and we are only told on the second page of the discussion that “the diagnosis of Wilson's was made by careful examination at the bedside of the eyes”. Yet the photograph of this difficult physical sign is not really very illuminating, and surely should have been presented during the case history. The book is mercifully short of repetitive themes, although two separate cases present demyelination masquerading as a mass lesion.

    Overall this is a successful armchair vehicle for discussing common problems in neurological diagnosis. It contains succinct and contemporary discussion of relevant pathogenic mechanisms, often genetic, even if arguably this is not the point of a compendium of case histories. One or two cases illuminate areas not really covered well in textbooks—the chapter on headache caused by sinusitis being an example. I suspect that it is those in training who will make most use of this book; some of the cases could be used by regional training advisers as vehicles for group discussion. But it is quite expensive for what I would see as a single usage book—would you read a compendium of case histories more than once?