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Chronic fatigue syndrome. Edited by David M. Dawson and Thomas D. Sabin Boston Little Brown 1993 240 pp illustrated $65

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BOOKS
Reviews
Clinical Autonomic Disorders: Evaluation and
Management
Edited by Phillip A. Lou,
Boston, Little, Brown, 199.3
832 pp* illustrated, $165.00
This comprehensive volume is an understandable and practical presentation of clinical autonomic disorders.
The book is divided into three sections: scientific basis,
clinical evaluation, and clinical disorders of autonomic function. The chapters on evaluation of autonomic function provide a useful description of the value and pitfalls of currently
available clinical tests. The 26 chapters on clinical disorders
cover a wide range of topics including autonomic neuropathies, central autonomic disorders, extrapyramidal disorders,
neurologic dysfunction of the bladder and gastrointestinal
tract, syncope, hyperthermia and hypothermia, sleep apnea,
male sexual dysfunction, autonomic emergencies, pain, reflex
sympathetic dystrophy, and disorders of sweating. The practical organization of topics will appeal to the clinical neurologist.
Each chapter begins with a useful summary of the main
points and ends with an adequate bibliography. The multiauthored format results in some repetition of information, but
the repetition allows each chapter to stand alone when the
book is used as a general reference. The index is user-friendly
and the diagrams are informative. This authoritative reference on clinical autonomic disorders is highly recommended
for all neurologists.
John W. Engstrom, M D
San Francisco. CA
Clinical Neurology, 1!992
Edited by Robert J . Joynt
Philadelphia, Lippincott, I 992
4.500 pp, illujtrated, $485.00
The 1992 edition continues the looseleaf arrangement that
permits replacement of individual chapters with periodically
updated versions. This format is designed to meet the competing demands of keeping the volume both comprehensive
and current. Each chapter addresses a specific class of neurological disease such as headache (Dewey K. Ziegler and Rchard W. Murrow) or a diagnostic modality like evoked potentials (Keith H. Chiappa and Prasanna Jayakarj. The breadth
of the volume is exemplified by chapters on neurological
rehabilitation (Joel S. Feigenson) and ethical issues in neurology (James L. Bernat), subjeccs that are often neglected in
less comprehensive works. The text falls short of being encyclopedic, however, as little attention is paid to some topics
like sleep disorders or sequelae of radiation therapy that do
not fit cleanly into one of the chapter headings. Other topics,
such as acquired immunodeficiency syndrome, are mentioned in several different chapters but do not receive a cohesive discussion.
250
The majority of the 66 chapters have been revised since
1988. Eleven of these were updated in 1992, including “Clinical Electromyography” by Bhagwan T. Shahani and Didier
Cros, “Drug Dependence” by John C. M. Brust, “Inborn
Metabolic Errors Affecting the Nervous System” by Kenneth
F. Swaiman and Glen Breningstall, “Neurologic Aspects of
Endocrine Disturbances” by A. Bernard Pleet and David J.
Saphier, and “Neuroepidemiology” by John F. Kurtzke. Each
chapter presents a thorough review of the topic with exhaustive literature citations. For example, “Ischemic Cerebrovascular Disease” (Martin K. Robinson and James F. OToole,
1787) opens with concise reviews of stroke epidemiology
and cerebrovascular anatomy. Clinical syndromes affecting
the carotid and vertebrobasilar territories are addressed in
turn and include discussions of management options for patients with TIAs or carotid stenoses. The chapter briefly covers the use of magnetic resonance imaging (MRIj, ultrasound,
and angiography and closes with discussions of stroke rehabilitation and prophylaxis.
As m g h t be expected in a volume of this nature, some of
the oldest chapters are less useful. “Intracranial Neoplasms
(1974)”does not describe modern classification ofgliomas or
focused cranial irradiation. Neither “Intracranial Neoplasms”
nor “Spinal Cord Tumors and Disks (1975)” discuss the use
of computed tomography or MRI in the evaluation of these
disorders. These omissions are addressed in part in a separate
chapter on neuroradiology (William A. Wagle, 1990),which
includes several dozen excellent quality reproductions of
high-resolution MRI and digital subtraction angiography. The
neuroradiology chapter also largely supersedes an earlier
chapter on MRI (1788), which suffers from images that are
of inferior quality by present standards. Like previous editions, the 1972 edition opens with a current therapy chapter,
which briefly describes the prevailing approaches to a wide
range of clinical problems. Although this chapter is perhaps
overambitious in scope, it does provide the reader with an
extensive and up-to-date reading list for each topic.
The volume generally succeeds as a current and comprehensive reference. Practitioners will find the text useful and
convenient as a first source. The extensive literature citations
make the volume particularly valuable to residents and students, for whom the reviews presented by each chapter provide a valuable context for assessment of the primary literature. With the annual chapter updates, Clinical Neurology can
serve as a comprehensive reference that stays abreast of advances in the field.
Raymond A. Swanson. MD
San Francisco, CA
Post-viral Fatigue Syndrome
Edited by Rachel Jenkins and James F . Mowbray
Chicbester,John Wiley, 1991
463 pp, $137.50
Chronic Fatigue Syndrome
Edited by David M . Dawson and Thomas D. Sabin
Boston. Little, Brown, 1993
240 pp, illustrated, $65.00
Copyright Q 1994 by the American Neurological Association
Chronic Fatigue Syndrome
Ciba Foundation Symposium 173
Edited by Gregory R. Bock and Julie Whelan
Chichestw.John Wiley. 1993
357 ppl 882.50
Like competing religions, rival theories about the etiology of
the chronic fatigue syndrome (CFS) tend to provoke controversy and acrimony, perhaps because there are SO few hard
facts to reason from. O n one side are ranged the true believers, who (like their patients) are convinced that CFS is a
physical disease (such as a chronic viral infection) which has
induced a profound yet subtle derangement of bodily functions, causing fatigue and multiple other somatic symptoms.
Their opponents regard CFS primarily as a form of somatization or depression, which may originally have been triggered
by a transient somatic illness, such as a viral infection. Advocates of the physical theory have to struggle with the stark
fact that no consistent clinical or laboratory signs of physical
disease have been established in CFS. Advocates of the psychogenic theory must deal with accusations of “delegitimizing” the experience of CFS patients, and with being unable
to prove that the prominent psychiatric symptoms of CFS
are primary rather than secondary.
Neurologists have mostly stayed on the sidelines of this
controversy. The absence of abnormal physical findings in
patients who claim to be severely disabled places CFS outside
the range of manifestations of known nervous system diseases. The voluminous CFS literature contains almost no articles written by neurologists. Yet many CFS patients are eventually referred to us for evaluation of complaints of fatigue,
weakness, limb pain, headaches, or difficulty concentrating.
I think that many neurologists would like to read a good,
short, impartial book about CFS. Unfortunately, none of the
three multiauthor books under review meets those specifications.
The book by Jenkins and Mowbray is a compendium of
the (mainly British) true-believer philosophy. Despite professions of objectivity and a “multidisciplinary approach,” most
of the book consists of unsubstantiated and often disconnected research results that are offered as evidence favoring
a viral cause of CFS, without considering the opposing evidence. The bias is crude and obvious. In a review of the
1948 epidemic of CFS in Iceland, Hyde and Bergman state:
“There was no evidence that these patients suffered from
hysterical, depressive or psychiatric disease.” To the contrary,
a neurologist who examined the patients 7 to 10 months later
found motor and sensory signs of hysteria in many cases [ I ] .
In another chapter, Jenkins, a psychiatrist, attempts to explain away various hysterical features of epidemic CFS; when
she confronts the “peculiar nature of the paresis” (giving-way
weakness, in fact), she abandons the argument and refers the
reader to later chapters about muscle pathology and virology!
Wessely’s account of the results of cognitive behavior therapy
stands out as the only useful contribution in this volume, but
the findings have been published elsewhere [2].
Dawson and Sabin are neurologists themselves, and their
book contains chapters on fatigue symptoms in multiple sclerosis, Lyme disease, and disorders of neuromuscular transmission, i.e., diseases that have no obvious connection with
CFS. Otherwise, their contributors stick mostly to the true-
believer party line. An exception is R. G. Miller’s chapter
on neurophysiological assessment, which argues convincingly
that fatigue in CFS is not caused by any abnormality of the
peripheral motor system, contradicting assumptions contained in several other chapters in the same volume.
I was especially puzzled by the lack of critical thinking in
the chapter about past epidemics of CFS. Dawson and Sabin
acknowledge that signs of conversion hysteria were reported
in many of the epidemics, starting with the very first one in
Los Angeles in 1934, but they seem to ignore the etiologic
implications of those observations. My own analysis of the
published reports shows that from 1934 to 1955, muscle
weakness was a prominent feature of all 10 CFS epidemics,
and was present in 48% of patients in the 8 epidemics for
which such data are available. After 1955, when the polio
vaccine was introduced, weakness was found in only 5% of
patients in the 7 epidemics that provide adequate data. Here
is a typical description of this weakness: “In the hypertonic
type, despite severe weakness, the muscles retained some
contractile power, but this was of a bizarre type. Great difficulty was experienced in initiating movement; and when contraction took place it was slow and clonic-like, both agonists
and antagonists appearing to contract simultaneously. Further, when these muscles were tested against resistance, they
contracted in a curious interrupted or cog-like fashion” [3].
Electromyographic (EMG) recordings obtained during the
1955 Royal Free hospital epidemic showed a peculiar grouping of motor unit potentials during voluntary contraction.
This pattern was thought to be a unique sign of the disease,
but was later recognized as typical of the intermittent voluntary effort seen in hysteria. Some of the same patients were
examined years later by P. K. Thomas and still had clinical
and EMG signs of hysteria [4].
The Ciba Foundation Symposium on CFS is heavily
weighted with participants who offer psychosocial explanations of the disorder; the two exceptions, neurologist P. 0.
Behan and internist Anthony L Komaroff, seem distinctly
uncomfortable as proponents of the minority true-believer
view. The free-wheeling discussions that follow each formal
presentation are the most rewarding part of the book; they
reveal that psychological explanations for CFS are just as frail
as virological theories. R. H . T. Edwards has an outstanding
chapter that, like R. G. Miller’s chapter mentioned above,
summarizes a large body of research (much of it carried out in
Edwards’s laboratory) demonstrating normal neuromuscular
physiology in CFS patients. Edward Shorter gives a brief history of psychogenic asthenia since the mid-nineteenth century; those who are interested in this subject should read
Shorter’s full account in his recent popular book [5}, or the
excellent article by Wessely relating CFS to Beard’s neurasthenia [ B ] .
In one of the Ciba Symposium discussions, the psychiatrist
Wessely remarked that “ME [myalgic encephalomyelitis or
CFS) patients came from all over Britain to see the top neurologists in the land. However, these same neurologists frequently disliked seeing ME patients-it is no secret that ME
is far from popular in neurological circles.” The concept of
neurasthenia was introduced in 1870 by an American neurologist, George Beard, to describe patients with purely subjective complaints very similar to those of CFS, and such
patients made up a large part of his practice. Most con-
Annals of Neurology
Vol 35
No 2
February 1994
251
temporary neurologists, however, will probably remain on
the fringes of the CFS scene, documenting normal neurological function (or signs of conversion disorder) in patients with
multiple somatic symptoms who lack objective signs of somatic illness. None of the three books reviewed here is likely
to attract neurologists into active participation in CFS research or treatment.
experimental therapy or a procedure to turn to in extremis.
It should be seriously considered in all cases of partial epilepsy after aggressive treatmenc fails with two appropriate
anticonvulsancs in monotherapy. This definitive text on the
subject is essential reading for all physicians who treat patients with epilepsy.
Robert B . L p e r , hlD
Suri Francijco, CA
New York, N Y
RderenceJ
Clinical Geriatric Neurology
Edited by L u k e Barclay
Malvern. Lea d Febiger, 199.3
5 13 pp, illustrated. $98.00
Thuddeuj Wulnak. M D
1. Sigurdsson B, Sigurjonsson J, Sigurdsson JHJ, et al. A disease
epidemic in Iceland simulating poliomyelitis. Am J Hyg 1950;
52:222-238
2. Butler S , Chalder T, Ron M, Wessely S. Cognitive behaviour
therapy in chronic fatigue syndrome. J Neurol Neurosurg Psychiatry 1991;%:193-158
3. Hill RCJ, Chetham RWS, Wallace HL. Epidemic myalgic enccphalomyelopathy. The Durban outbreak. Iancet 1959;1:689-693
4. Thomas PK. Postviral fatigue syndrome. Lancet 1987;1:218-219
5 . Shorter E. From paralysis to fatigue: a history of psychosomatic
illness in the modern era. New York: Free Press, 1992
6. Wessely S. “Old wine in new bottles”: neurasthenia and “ME.”
Psycho1 Med 1990;20:35-53
Surgical Treatment of the Epilepsies, Ed 2
Edited b.; Jerome Engel. Jr
New York, Raoen Press, 1993
786 pp. illustrated, $135.00
This excellent book results from the Second Palm Desert
International Conference on the Surgical Treatment of Epilepsy. The second edition follows the first Palm Desert Conference and the resulting first edition by more than six years.
These years have seen an explosion in the number of centers
offering epilepsy surgery and in information regarding the
indications, evaluation, and results of epilepsy surgery. These
changes are ably reflected in the new edition, which bears
only passing resemblance to the first.
The book far surpasses publications resulting from most
conferences for several reasons. First, D r Engel insisted that
preliminary versions of chapters be written well before the
conference. Authors were to develop consensus on various
topics relating to epilepsy surgery. Participants were given
copies and encouraged to read these before the conference.
The resulting focused discussions were usually incorporated
into the final versions of the chapters. Second, participants
were asked to complete extensive surveys regarding important issues in epilepsy surgery and generally did so. The resulting data, while not epidemiologically rigorous, provide
the most extensive information currently available on approaches to evaluation and results of epilepsy surgery. Finally, virtually all contributors describe how consensus has
evolved and provide concise summaries.
The result is the definitive textbook on the subject. The
book is logically organized, illustrations are of good quality,
and tables are used frequently and appropriately. There is
detailed discussion of when to refer patients and of results
of epilepsy surgery. Concise chapter summaries allow quick
review for the busy practitioner. Epilepsy surgery is no longer
252
Annals of Neurology
Vol 35 No 2
February 1994
Here comes Laurie Barclay and her 57 contributors with
a new book of geriatric neurology. What makes this text
outstanding? The book is divided into 12 sections with several chapters in each. It opens with an overview section with
chapters on normal agmg and an exposition of geriatric neurology itself. The trend that separates this book from most
neurology texts begins in the first section in which a chapter
describes the effects of aging on the organ systems other
than the nervous system. This emphasis on extracranial dysfunction underscores one of the lessons of geriatrics: the
body works as a unity and even the brain needs support from
its neighbors. The direct effect of extracranial illness on the
nervous system comes in a separate chapter. The two complementary chapters provide a broader exposition than seen in
neurology books. The section describing changes in consciousness also stresses the relationship between general illness and neurological illness. A clinically savvy chapter discusses the neurology of coma but less expected is the
nonneurological discussion of syncope. A third chapter supplies the neurological lowdown on seizure disorders. Together, the chapters illustrate the dichotomous approach
needed to evaluate a patient who passes out.
The section on cognitive disorders adds a chapter on ageassociated memory impairment and one on the ethics of caring for Alzheimer’s patients, to the expected discussions of
dementia found in neurology books. An excellent chapter,
later in the book, describes specific methods for taking care
of demented patients.
Other chapters deliver neurological information about
movement disorders, stroke, tumor, trauma, and other intracranial disorders. The chapters that stray out of the neurological perimeter will attract a neurologist most to this book. The
chapter on medical complications of neurological disorders
discusses decubitus ulcers, gastric motility, and other issues
that plague neurological patients, especially those with
chronic diseases. Depression, sleep disorders, pain management, and urinary incontinence find a place in the section on
management of symptoms. The section on treatment strategies in geriatrics finishes the book by covering broad areas of
surgical, pharmacological, rehabilitation, and long-term care.
The several chapters that discuss the geriatric approach to
patient care will inform and irritate traditional neurologists.
The chapter on multidisciplinary team practice emphasizes
consensus diagnosis and treatment among providers with different skills but does not acknowledge that every kitchen
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syndrome, illustrated, sabine, little, 1993, dawson, 240, thomas, edited, brown, david, boston, fatigue, chronic
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