beyond the fifth sense
TRANSCRIPT
In Context
120 www.thelancet.com/neurology Vol 10 February 2011
There is a sort of morbid fascination that many of us share about the several and varied disorders of the brain and mind. Case studies of loss—of memory, of names, of colour vision—fi ll publishers’ lists. I’m not talking about academic textbooks here, but trade books addressed to the lay public. Novelists write about the devastation wrought by Alzheimer’s disease in the minds of their mothers or lovers. Neurologists write about their patients, or thinly disguised variants of them, with Antonio Damasio, Vilayanur Ramachandran, Paul Broks, and of course the doyen of them all, Oliver Sacks, all taking up their pens to share their experiences.
Born in London and professor of neurology at New York’s Columbia University, Sacks fi rst became known to the general public through his book Awakenings, a remarkable account of the extraordinary eff ects of the then revolutionary drug levodopa on his patients. Awakenings and a series of subsequent books have inspired both fi lms and a play—The Man Who Mistook His Wife for a Hat was adapted by the great director Peter Brook in close conjunction with Sacks.
What gives these books their particular strength is Sacks’ capacity to convey huge warmth and human sympathy—perhaps empathy would be a better word—for his patients without ever losing his clinician’s objective eye. However, as I read the opening pages of The Mind’s Eye, I felt that there must surely be a saturation point beyond which further case studies cease to be of general interest and become of concern only to the patients, neurologists, and individuals attempting to construct coherent theories of how the brain works from the quasi-experiments that accidents, stroke, or Alzheimer’s disease provide.
For the fi rst three chapters, my pre-judgment was increasingly confi rmed. Here are more patients, unable to recognise words or navigate the world but who have other facilities remarkably spared, such as playing music by ear rather than reading. Every case is discussed with Sacks’ customary sympathy and facility, but what more was I, a non-clinician, learning from these accounts? There is a dispute among biologists that runs back to at least the mid-
Beyond the fi fth sense
The Mind’s Eye By Oliver Sacks. Picador,
Pan Macmillan, 2010. Pp 260. £17.99.
ISBN 978-0-33-050889-6.
BooksNeuro-oncology updatedCancer is a leading cause of death, especially in high-income countries, and about 20% of patients with generalised malignancy will develop neurological complications, heavily aff ecting quality of life and prognosis. Neuro-oncology is a relatively new specialty in neurology, born from the need for rapid diagnosis and adequate management of neurological diseases associated with cancer.
In recent years, several textbooks have covered the fi eld. The present volume edited by Newton and Malkin attests to the increasing interest in this specialty. Neurological Complications of Systemic Cancer and Antineoplastic Therapy covers almost every aspect of the neurological disorders associated with systemic malignant diseases. Five chapters are devoted to metastatic locations aff ecting intracranial structures, epidural space, leptomeninges, cranial nerves, and plexuses. Four others discuss complications of radiotherapy, chemotherapy, immunotherapy, and side-eff ects of steroids and supportive care (although no separate section is devoted to sequelae of surgery). Another section updates readers about the diagnosis and treatment of paraneoplastic disorders.
The occurrence and features of neurological complications vary with the cancer type, and this book describes the neurological diseases that specifi cally occur in lung or breast carcinomas, melanoma, leukaemia and lymphoma, head and neck, gynaecological, gastrointestinal, and genitourinary cancers, sarcoma, and myeloma. This broad discussion is one of the strong points of the textbook,
because several predecessors mainly covered only the fi rst three primary tumours. Equally valuable is the chapter devoted to recent advances in molecular biology and the pathological changes of CNS metastases.
As indicated by its title, the book emphasises antineoplastic therapy. Treatments of metastatic lesions, the most common complications, are often discussed twice. The results of several therapeutic trials are carefully analysed. However, it is not always easy to draw clear guidelines from such an abundance of material presented by diff erent authors. I fully realise that clear therapeutic algorithms and guidelines can easily become simplistic and obsolete. Metastases involving the nervous system are seldom isolated diseases. Their treatment must integrate several aspects such as the patient’s performance status, the spread and progression of both nervous and systemic lesions, and primary and acquired resistance to treatments. However, despite being opinion leaders, several authors of the chapters that consider treatments fail to give their counsel on the current state of the art, which is what many colleagues, especially those who are not experts in neuro-oncology, are looking for. With this minor (and subjective) reservation, I fi nd the book highly recommendable to all those who face neurological disorders in patients with cancer.
Jerzy [email protected]
Neurological Complications of Systemic Cancer and
Antineoplastic TherapyEdited by Herbert B Newton
and Mark G Malkin. Informa Healthcare, 2010.
Pp 594. €188.00. ISBN 978-0-84-939191-0.
In Context
www.thelancet.com/neurology Vol 10 February 2011 121
19th century as to whether physiological processes can best be understood by studying the normal or the abnormal diseased or damaged organism. Although Sacks makes a strong case for the insights provided by the abnormal in interpreting brain function, I am only partly convinced.
Suddenly, in chapter 4, everything changes. Sacks begins to discuss his own visual recognition problems—specifi cally, a long-standing mild form of face-blindness (prosopagnosia). And then, for him, disaster strikes. He begins to lose vision in his right eye as a result of a growing melanoma. His journal records the increasing visual problems, and what he can and cannot see. Initially, his treatment is successful but a later episode of retinal bleeding leaves him with no stereoscopic vision and right visual fi eld neglect. Buttressed by the care of his long-term friends and assistants, he reconstructs his life, learning through comparing his experiences with those of many others, including neurologists, who have had to come to terms with visual impairment or blindness.
Always perceptive of other people’s problems, Sacks now has to be perceptive about his own. To perceive in its original sense means to take in through sight or other senses. This taking in is exactly what, for Sacks, has become impaired. But, in a more recent sense, perceiving also
means apprehending with “the mind’s eye”. And it is with his mind’s eye that Sacks must now learn to compensate for his inability to see in depth or to be aware of what is happening in what would be his right fi eld of vision.
The eff orts he has to make and the successes he records—both for himself and for others aff ected by brain or sensory damage—lead him to refl ect on the plasticity of the brain. As recent decades of research have shown, it is not just during the rapid development of the fetal, infant, and child’s brain that experience moulds and transforms neuronal pathways and synaptic connections. Even into late age, such connections are highly dynamic, as the self-organising brain constantly rewires itself. Use, disuse, and damage can trigger neuronal reorganisations that earlier generations of neuroanatomists would have regarded as impossible. But far more striking even than the powers of the brain to reorganise itself are the capacities of sentient individuals to adapt and compensate, and to fi nd alternative and novel coping strategies. Oliver Sacks’ new book both documents these capacities and, in doing so, becomes in itself a tribute to the power of the mind and spirit.
Steven Rose [email protected]
Refractory migraine and its daily clinical challenges In this book, the editors have assembled a team of experts to present and discuss an important topic in the headache fi eld—refractory migraine. Starting with the recently proposed criteria for defi ning refractory headache, and refractory migraine in particular, Schulman, Levin, Lake, and Loder have chosen headache luminaries to discuss some controversial topics related to the assessment and treatment of patients with headache that is diffi cult to treat and that is the biggest challenge for headache practitioners.
Ranging from possible pathophysiological mechanisms to the increasing importance of psychiatric comorbidity—without forgetting crucial topics such as overuse of symptomatic drugs, nerve blocks, neurostimulation, and non-pharmacological treatments—the contributors to this book also call attention to the perils and pearls of daily practice with these patients and explore the particularities of specifi c populations, such as women, children, and adolescents. The result is a thorough and systematic review of the available literature.
The book is well written, up to date, and is a valuable guide for clinicians and researchers. Valuable experience of daily practical approaches from veteran expert clinicians such as Mathew, Rothrock, Saper, Purdy, Tepper, and others is presented in addition to the literature published in the past decades. The readers will be able to explore in detail the current data and evidence-based approaches but might
miss further insights into daily management tactics from pioneers in the fi eld of headache.
Because there is still little consensus on refractory headache, even on its defi nition, there is plenty of room for more discussion. An interesting chapter is devoted to refractory headaches other than migraine, with an emphasis on the poor prognosis of available treatments. Although the clinical experience of some contributors is mainly theoretical, most are successful in highlighting the importance of a combination between diff erent pharmacological drugs and between pharmacological and non-pharmacological treatments, which remains a matter of controversy among clinicians from diff erent geographical areas.
Additionally, the contributors address practical daily clinical points to establish a more solid foundation for successful treatment and present possible recommendations for professional services provided to these patients.
Refractory Migraine is a must-have book, providing a taste of a new era in headache management. The traditional comprehensive review provided by headache textbooks is expanded with chapters highlighting some of the daily clinical challenges faced by those dealing with patients who are refractory to more usual and conservative approaches.
Abouch Valenty [email protected]
Refractory Migraine: Mechanisms and ManagementEdited by Elliot A Schulman, Morris Levin, Alvin E Lake III, and Elizabeth Loder. Oxford University Press, 2010. Pp 496. $79.95. £50.00. ISBN 978-0-1953-9469-6