Neurology

Lecture Notes on Neurology

Lecture Notes on Neurology. Sixth Edition

Ivan T. Draper

Boston, MA, Blackwell Scientific Publications, 1985. 217 pp.

This is the sixth edition of this concise, pocket-sized review text. One of an extensive series of similar works by British authors, this book seems aimed primarily at undergraduate medical students or other non-neurologists interested in a broad overview of the field.

Dr. Draper, neurologist at the Institute of Neurological Sciences in Glasgow, has divided his work into three major parts: Structure and Function of the Nervous System, History and Examination, and Diseases of the Nervous System. The individual chapters are well organized and well written, making it possible for the reader to review the basic information concerning a neurological subject in a matter of minutes.

Omissions are almost inevitable in a book of this size; although it is not a comprehensive textbook, one would have hoped to have found discussion of such topics as magnetic resonance imaging (MRI) and fungal meningitis, which are not covered. References for futher reading are not provided, leaving the reader with no entree into the neurologic literature if elaboration of an obscure or controversial point is desired.

In spite of these faults, the book is not without its merits, including an evenness in style that makes it a pleasure to read. Some sections, such as that on the history and examination, are especially good. It is recommended as a convenient reference for the non-neurologist.

Handbook of Parkinson’s Disease

Handbook of Parkinson’s Disease

Edited by William C. Koller

New York, Marcel Dekker, Inc., 1987. 505 pp.

Although the tremor of Parkinson’s disease has been described intermittently throughout recorded history, the increasing life expectancy of human beings has made it a commonly treated illness today. Due to its slow progression and many coexistent symptoms, it is quite likely that most medical practitioners will encounter patients with this disease. Recognizing the need to understand and treat this debilitating illness, James Parkinson ended his 1817 description of shaking palsy with this admonishment to basic and clinical scientists:

Before concluding these pages, it may be proper to observe once more, that an important object proposed to be obtained by them is, the leading of the attention of those who humanely employ anatomical examination in detecting the cause and nature of diseases, particularly to this malady. By their benevolent labors its real nature may be ascertained, and appropriate modes of relief, or even of cure, pointed out.

Dr. Koller and his associates have answered his call by producing a handbook that provides up-to-date information on the pharmacology, physiology, pathology, and psychology of Parkinson’s disease. In this comprehensive text, topics range from genetics to stereotactic surgery and include such varied subjects as pharmacologic therapy, rehabilitation, epidemiology, and history. There are also chapters that deal with patient concerns, such as sleep disorders and psychosocial interaction. The appendix includes common staging scales, drug availability and cost, organizations that help patients to cope with their disease, and books that the patients can consult to understand it. The danger in attempting to produce a book of such magnitude is the creation of a tedious morass that a reader must wade through to find the useful facts, but the contributors to this book fall into this pitfall only occasionally.

On the whole, I found this handbook to be well written, well referenced, and interesting. Dr. Koller’s text offers the clinician current useful information about the disease and gives the researcher a comprehensive review of the progress other disciplines have made to understand and treat Parkinson’s disease.

Disorders of the Developing Nervous System

Disorders of the Developing Nervous System: Changing Views on Their Origins, Diagnoses, and Treatments

Edited by John W. Swann and Anne Messer

New York. Alan R. Liss, 1988. 269 pp.

Disorders of the Developing Nervous System: Changing Views on Their Origins, Diagnoses, and Treatments is a volume based on the proceedings of the Birth Defects Symposium XVIII, held in Albany, New York, in September 1987. The book contains thirteen chapters written by 32 individuals, and is edited by John Swann and Anne Messer of the Birth Defects Institute, New York Department of Health. A possible criticism of this book is that many of the experimental findings are published by these authors elsewhere (e.g., The New England Journal of Medicine, Neurology, and Annals of Neurology). This circumstance is often a characteristic of books derived from symposia, however, and the strength of this work lies not in the novelty of its experimental results, but rather in its broad and masterful coverage of numerous “hot” areas in neurobiology. Thus, the reader is introduced to neuroimaging techniques being employed for the diagnosis and study of neurological disorders (e.g., PET scan in the diagnosis of epilepsy, MRI changes specific to the cerebellum of autistic individuals), the role of NMD A receptors in mechanisms of hypoxic-ischemic brain injury, and gene mapping and cloning in Duchenne muscular dystrophy. Other disorders dealt with in this book are cerebral palsy, dyslexia, Down’s syndrome, PKU, and storage diseases.

The individual chapters are written with exceptional clarity, and are easy to follow; each contains appropriate amounts of background information to orient the reader, which is probably due to the fact that each chapter is based on a talk at the Birth Defects Symposium. Although the central themes of this volume are the developing nervous system and childhood disorders of the nervous system, several papers contain information relevant to disorders of the adult nervous system (e.g., hypoxia-ischemia, epilepsy, and Alzheimer’s disease). This feature will undoubtedly provide the book with a larger audience. In addition, its emphasis on histopathology (especially those chapters dealing with neuroanatomic changes observed in autism), will be of interest to neuropathologists. The majority of the chapters are extremely readable and provide enough interesting information to maintain the reader’s attention, without becoming overly detailed and dry. Certain chapters tend toward the obscure, however, and their subject matter is more difficult to follow. This criticism is particularly true of the chapter entitled “Timing of cell interactions in cerebellar development.” The chapter contains a veritable maelstrom of information on cerebellar mutations in several mice strains (e.g., sg/sg, Lc). In addition, the chapter entitled “Synaptic mechanisms of focal epileptogenesis in the immature nervous system” would be more readily understood if it contained a more extensive introduction to elementary neurophysiology.

On the whole, I would recommend this book. I think it will be of interest to adult and pediatric neurologists, neuropathologists, and neurobiologists. Its strength lies in its clear presentation of the research being conducted in neurobiology today.

The Human Brain

The Human Brain

Paul Glees

New York, Cambridge University Press, 1988. 204 pp.

In his most recent book, The Human Brain, Paul Glees, Emeritus Professor of Neuroanatomy and Histology at the University of Gottingen, attempts to expand upon two of his earlier works (Das Menschliche Gehrin [1968] and Experimental Neurology [1961]). As the author states, the book draws upon his “experience and accumulated teaching material,” especially his recent teaching experiences at Cambridge University. Although the book is relatively short, its approach to neurobiology is strikingly comprehensive. Glees places great emphasis on anatomy (human and comparative), embryology, and histology, but there are also numerous small pockets of neurophysiology and neuropathology, with occasional clinical correlations. Much of the first part of the book, in particular, is written for the novice in neurobiology. Its style is simple, with an emphasis on basics. There are many interesting figures and drawings; the first 20 pages of the book contain 30 figures. Despite the often simple style, it is one of the rare books which may be read on several levels, and its figures contain large quantities of valuable information.

The book possesses a number of strengths, the first being its evolutionary approach to neurobiology. This approach is particularly apparent in chapters one and two. Thus, there is a significant amount of comparative anatomy, and the reader gains a sense of the development of the human brain over time. The phylogenetic approach, missing from most books, provides this one with added value. The above-mentioned evolutionary/phylogenetic approach extends to the author’s explanations for the relative development of certain brain structures. These explanations tend to have a teleological flavor, making them somewhat simplistic, though often intriguing. While the author’s evolutionary approach often gives the reader additional information, at times the information is incorrect. Thus, Figures 2.1 and 2.12 contain major paleo-anthropological errors. For example, David Pilbeam’s work in the Siwalik hills has demonstrated that the sivapithecines were probably an early form of orangutan rather than early hominids. Moreover, Paranthropus, a taxonomic term applied to the robust South African australopithecines, is a term that was largely abandoned in the early 1950-s as a result of the work of Le Gros-Clark, S.L. Wasburn, and others. These errors may be attributed, in part, to the author’s references, which are rapidly becoming outdated (e.g., De Beer’s Bildatlas der Evolution [1964], Howells’ Early Man [1966], Day’s Guide to Fossil Man [1967], and Le Gros-Clark’s History of Primates {1958]).

For the most part, the book is comprehensive and well organized, containing 14 chapters on subjects ranging from the peripheral nervous system (”Touch, pain and proprioception”) to the central nervous system (”The cerebral hemispheres,” “The brainstem and cerebellum”). The chapter which deals with neuroglia is particularly interesting; it is here, perhaps more than at any other point in the book, that the author divulges some of his knowledge and tremendous expertise.

Apart from the volume’s scattered grammatical errors, sentences are often convoluted and difficult to understand. It is unclear whether this flaw may be attributed to the author’s style or to the nature of the translation; however, some passages are misleading, a particularly worrisome fault in a book intended for novices. For instance, the following sentence implies that there is no cardiopulmonary circulation: “As already emphasised in the section on brain metabolism, the supply of nourishment originating in the liver reaches the brain via the vascular system.” Furthermore, there are quite a few errors in the book’s figures (e.g., in Figure 7-6, CA, cerebral aqueduct, is labeled AC, anterior commissure; in Figure 7-7, dln, dorsolateral nucleus, is labeled ins, insular cortex).

Despite these relatively minor flaws, this book distinguishes itself because of the organization, wealth of information, and evolutionary and teleological approaches. Most notable, however, is the fact that it may be read on multiple levels. For this reason, I would recommend The Human Brain to a broad audience, either as an introduction to the field of neurobiology or to reacquaint the reader with the basics and to gain a different (that is, teleological) perspective.

Vision and the Brain

Vision and the Brain: Organization of the Central Nervous System

Edited by Bernard Cohen and Ivan Bodis-Wollner

New York, Raven Press, 1990. 364 pp.

While experimenting with retinal ganglion cells of cats in 1966, Enroth-Cugell and Robson made one of the major breakthroughs of the century in vision research. They showed that these cells, capable of firing action potentials, are organized in relation to simple receptive fields on the retina centralis. This work pioneered the ongoing effort to understand how light-induced signals are graded, distributed, and processed from the retina to the thalamus to the cortex (and within the cortex), making visual function possible. Vision and the Brain: Organization of the Central Nervous System, edited by Bernard Cohen and Ivan Bodis-Wollner, attempts to bring the reader up to date on the latest research in this fascinating and dynamic field.

Vision and the Brain is volume 67 in a series published by the Association for Research in Nervous and Mental Disease. The organization has been sponsoring a new volume about once a year since 1920. Vision and the Brain is the product of 37 authors, and contains 161 illustrations. It is drawn from the authors’ original works and compiled from eighteen papers, each complete with a set of references. The volume is supplemented with an extensive index.

Vision and the Brain reads more like a textbook than a collection of many authors’ writings. In general, each chapter provides a clear and concise overview of the topic under consideration that the non-expert can easily understand and appreciate. This overview is followed by descriptions of potential domains of research as well as a summary of the authors’ pioneering work in the field. The book begins with a thorough examination of the functional and pharmacological organization of retinal cells. Here, much attention is given to the horizontal cell and the role of dopamine as a modulator of lateral inhibition — a phenomenon that aids in the visual recognition of edges. Next, the authors discuss the different transmitters mediating systems within the lateral geniculate nucleus, thus summarizing the pre-cortical processing of visual input.

Most of the book is dedicated to describing the complex interpretation of images at the level of the cortex. A summary of the encoding of objects in their shapes, color, movement, and depth is provided in an enjoyable chapter which explains some of the rationale behind optical illusions. This material is followed by a detailed analysis of neural velocity field computation, recognition of facial expression, motion processing, and the coordination of eye movement. An interesting discussion of the use of positron emission tomography to help map visual cortex functioning is also included.

For the neurology student, this book can be an amusing and up-to-date summary of visual processing systems. For the clinician, it also sheds light on the visual disturbances associated with such conditions as Parkinson’s disease, Altzheimer’s disease, and multiple sclerosis. For the vision researcher, it serves as a convenient collection of some of the field’s pioneering work. In any case, it comes with a hefty price tag.

Neurologic Emergencies

Neurologic Emergencies. Recognition and Management. 2nd Edition

Edited by Michael Salcman

New York, Raven Press, 1990. 442 pp.

The second edition of Salcman’s Neurologic Emergencies. Recognition and Management is an excellent resource manual for non-specialists responsible for early management of neurologic emergencies. Its chapters are brief and consistently pertinent in guiding the evaluation and initial treatment of neurologic presentations ranging from headache and backache through major trauma and stroke.

The book is divided into five sections. The first chapter in section one, on “general considerations,” reviews the pathophysiology common to cerebral infarction, hemorrhage, and trauma. The second chapter provides a clear exposition on the approach to the unconscious patient — always a demanding diagnostic challenge; this chapter also sets the standard for most of the following chapters by including a simple and very valuable algorithm illustrating a logical approach to the presenting problem. Section one concludes with a chapter on cardio-respiratory management in neurologic emergencies.

Section two on stroke and tumor contains useful chapters on subarachnoid hemorrhage (including a differential diagnosis of headache), stroke, and neoplastic emergencies.

Neurologic trauma is reviewed in section three. The first chapter, head injury, provides an algorithm for evaluation and treatment, summarizes medical problems often associated with major head injury, and reproduces the University of Maryland neuroassessment flow sheet as a model for documenting the ongoing status and care of injured patients. The chapter on spine injury and acute paralysis is a brief, logical, and readable summary on evaluation and treatment. A half-page presentation on reading plain spine X-rays is in itself worth the price of the book. The chapter also contains useful algorithms on compressive traumatic lesions, disruptive lesions, pyogenic lesions, and vascular occlusive lesions. The chapter on acute nerve root compression and backache describes these common syndromes in a clear manner and also defines the circumstances under which emergency consultation is mandatory. Careful attention to this subject will save many patients — and doctors. The section on trauma concludes with evaluation of peripheral nerve injury.

There are six chapters in the section on medical neuro-emergencies: seizures, polyneuropathy, respiratory muscle failure, encephalitis, meningitis, and toxic-metabolic encephalopathy. All are concise and logical in presentation. The chapter on toxic-metabolic encephalopathy, including an excellent algorithm, provides in a mere 35 pages information sufficient to diagnose and treat the majority of presentations of altered mental status.

Salcman’s book concludes with a two-chapter section on pediatric neurologic and neurosurgical emergencies. Both chapters review the similarities and differences in early management of pediatric and adult patients; both provide a useful, albeit very brief, review of these fields.

Clearly, this is a book to be enthusiastic about, and I recommend it highly to all who deal with neuro-emergencies. One pet peeve about terminology, however: if my profession is to be named by the location of where I work, i.e., “emergency room doctor,” then Dr. Salcman is an “operating room doctor.” Furthermore, if the suite of rooms in which emergency care is practiced is an “emergency room,” then why not “critical care room” or “intensive care room”? I am disappointed to see these obsolete terms perpetuated in such an outstanding book.

Essentials of Clinical Neurology

Essentials of Clinical Neurology

Carl H. Gunderson

New York, Raven Press, 1990. 550 pp.

Essentials of Clinical Neurology is an intermediate-sized tome on neurological diagnosis and treatment. From the start, the author states that his goal is not to follow the examples of other “encyclopedic” volumes such as Merritt or Adams and Victor, but rather to provide a distilled body of facts.

The book is organized into four parts. Part one, “Introduction to Neurological Evaluation,” provides brief introductions to the currently available neurodiagnostic modalities, including the electroencephalogram (EEG), electromyogram (EMG), computerized axial tomogram (CAT), and magnetic resonance imaging (MRI). As is true of the remainder of the book, this part is well organized and quite easy to follow. In general, the reproductions of MRI and CT scans are of good quality. Part two, “Analysis of Common Neurological Complaints,” contains chapters on movement disorders, sensory disorders, neurology of vision, headache, dementia, and aphasia. Each chapter initially provides a review of the basic neuroanatomy and neurophysiology; these reviews are particularly well done in the chapters on movement disorders and the neurology of vision. Much of the emphasis is on diagnosis, and each chapter provides pertinent aspects of patient history, the neurological exam as well as a condensed differential diagnosis. Parts three and four discuss differential diagnoses and selected neurological diseases.

A strength of this book is its organization. First, it is written in outline format. In addition, the basic terminology is not assumed, and all terms (e.g., hypotonia, akathisia) are well defined; however, I did not really find the distinction between the major subheadings (parts two through four) to be very helpful. Another criticism is that certain areas, such as child neurology, are entirely lacking, although the author does mention this as a shortcoming in the introduction.

Despite these criticisms, this work is an exceptionally well-assembled volume. What distinguishes it from others is the author’s gift of distilling information. He intentionally avoids the encyclopedic approach, while, at the same time, avoiding the pitfalls of many of the smaller manuals which provide choppy, partially digested bits of information. The choice of facts leaves the reader with a true gestalt of neurological disease. The emphasis on basic physiology, diagnosis, and treatment makes the book particularly appropriate for neurology residents.

Comprehensive Neurology

Comprehensive Neurology

Edited by Roger N. Rosenberg

New York, Raven Press, 1991.920 pp.

Comprehensive Neurology proposes to review “all aspects of neurologic disease,” providing yet another addition to the ever-growing list of neurology references. Its editor, R.N. Rosenberg, claims substantial experience in neurology editorship with The Treatment of Neurological Diseases (1979), Neurology (1980), and the five-volume Clinical Neurosciences (1983); more recently, he has produced shorter studies, including Neurogenetics: Principles and Practice (1985) and Molecular Biology of Neurological Disease (1988). In contrast to other textbooks like Asbury, Mckhann, and McDonald’s Diseases of the Nervous System, which contain two cumbersome volumes of material, Rosenberg hopes with the present volume to produce a comprehensive neurological reference in a single volume, while providing a “detailed, scholarly account” of neurological diseases, synthesizing the basic and clinical neural sciences for clinicians and interested researchers.

Unfortunately, Rosenberg only partially accomplishes his goal, instead producing a book that conveys a fragmented view of neurology. Compared to other comprehensive textbooks, like Asbury et al.’s Diseases of the Nervous System, or even smaller works much as Rowland’s Merritt’s Textbook of Neurology, Rosenberg’s haphazard contribution simply pales. Comprehensive Neurology attempts to touch upon every aspect of neurological disease with chapters by various specialists, on topics from teratology to psychiatric disorders to coma; but the book fails to tackle an in-depth discussion of neurology. Indeed, most chapters do not consider all aspects of their respective topics, and the accounts tend to be either all-encompassing but superficial or else informative but specialized. For example, such chapters as “Diseases of the Autonomic Nervous System” or “Cerebellar Disorders” provide only brief descriptions of clinical phenomena, while “Headache Syndromes” and “The Comatose Patient” provide informative detail on pathogenesis, clinical presentation, and treatment, albeit limited to their specialized disease. The book treats more general topics rather lightly, though it offers excellent timely information on particular specialized subjects. The result is, by avoiding a thorough coverage of basic neurological concepts and disorders, its utility as a reference diminishes.

Comprehensive Neurology further suffers from a lack of focus or direction in editorship. The table of contents itself reflects a dense conglomeration of chapters without any obvious logical sequence. Many chapters overlap in coverage of several topics, including such conceptual issues as the principles of magnetic resonance imaging and computerized tomography, or such background issues as the neuroanatomy of the vestibular or ocular systems. As the most obvious example, even though Rosenberg generally devotes, at most, one chapter to individual sensory systems, the eighth nerve system alone receives two chapters of coverage, and the majority of their content reiterates information found in other chapters. Moreover, despite Rosenberg’s expressed desire to coordinate basic science with clinical disease and treatment, chapter formats vary tremendously, with some chapters presenting mostly background information, like G. Rosenberg and Wolfson’s chapter on brain fluid and electrolyte disorders, while other chapters present only clinical information, for example, Damasio and Tranel’s chapter on disorders of higher brain function. Some chapters even stray from their title topics: Hecox and Hogan’s chapter, “Diagnostic Principles in Neuro-otology,” for instance, scarcely even addresses diagnostics and instead focuses on neuroanatomy and physiology, while Richter and Corder’s “Neurotoxic Syndromes” chapter concentrates mostly on substance abuse, virtually skipping the role of biological toxins or metabolic toxicities. On the other hand, such chapters as Kase et al.’s on cardiovascular disease, Chad and Munsat’s on muscular disease, and Wray’s on neuro-ophthalmologic disorders clearly and concisely provide thorough, up-to-date information about their respective fields. Laudably, these chapters provide informative, thoughtful presentations. In my view, this volume contains a great diversity of writing quality and content, reflecting an editorship that allows the book’s contributors overmuch free rein to digress. The end product strays too far from the claim “comprehensive neurology.”

In light of other alternative neurology references, a clinician or any interested scientist might therefore find little of interest in Rosenberg’s Comprehensive Neurology, other than some specialized topics such as multiple sclerosis, metabolic encephalopathy, and the aforementioned cardiovascular, muscular, and ophthalmologic diseases. The book’s chapters generally offer unsatisfying whirlwind tours of neurological disorders, never providing a unique or novel presentation of the material. Other contemporary works provide identical information, presented in a more pragmatic, informative, and concise manner, such as Swash and Oxbury’s Clinical Neurology (1991) or, particularly, Asbury et al.’s thoughtfully organized and edited Diseases of the Nervous System (1992). Rosenberg’s present work fails to satisfy the requirements for a comprehensive neurological work in one volume because it rambles through neurological discourses. The editor and his contributors have unfortunately and disappointingly produced a weak overall contribution to the neurological library.

Stress: Neurobiology and Neuroendocrinology

Stress: Neurobiology and Neuroendocrinology

Edited by Marvin R. Brown, George F. Koob, and Catherine Rivier

New York, Marcel Dekker, Inc., 1991. 703 pp.

Stress: Neurobiology and Neuroendocrinology is an ambitious attempt to review the latest work in stress research to, state the editors, stimulate “… the development of innovative methods … for further studies in stress biology.” The work presents a great deal of data on stress biology, endocrinology, and physiology, and is for the most part a well-written and fully referenced contribution to the field of stress research.

The book, a collection of 29 reviews by biomedical faculty at American institutions, is organized into four main sections: (1) a general overview regarding issues defining and measuring stress; (2) basic central nervous system (CNS) and endocrine biology during stress; (3) discussions of pathophysiology resulting from stress, such as ischemia, gastric ulcers, immune dysfunctions, and psychiatric disorders; and (4) stress management strategies with explanations of how they may work.

Section three, which concerns itself with stress pathophysiology, is perhaps the book’s strongest section. Here the authors effectively demonstrate links between stressful events and eventual disease processes and provide critical reviews of their fields. For example, Chapter 3 tackles the role of mental stress in causing myocardial ischemia. The authors persuasively argue for ischemia as the best measurement of cardiac pathology vis-a-vis stress, and reproduce studies of ischemia during mental stress over an array of diagnostic modalities (technetium, echocardiography, PET). They further proceed to explain the possible endothelial pathophysiology in response to acetylcholine, resulting in coronary vasoconstriction and subsequent ischemia. In their summary, the authors lucidly delineate avenues of further research.

Chapter 27 reviews stress-induced immune dysfunction in humans. In this chapter, the author ably points out the gap in current research: although studies exist which show an association between psychological stress and immune changes, and psychological stress and disease, there exists a dearth of studies to demonstrate a clear association among all three. He questions the current assumption of the role of endogenous cortisol in immunosuppression by showing studies in which elevated cortisol during stressful events did not always result in depressed natural killer cell activity. Laudably, the author does not leave the reader to wonder about other mechanisms of immune suppression and presents studies which demonstrate that the autonomic nervous system may be ultimately responsible.

The book’s major missed opportunity is a cohesive chapter which connects the disparate discussions of neurobiology and pathophysiology. Chapter 2, the closest stab at this goal, is clearly written, yet digresses into dozens of areas. Instead, a lucid summary of the basic science chapters which follow, demonstrating stress as an insult to the CNS and the endocrine system, which filters down to other organ systems, would have been highly valuable. Aside from suggestive studies, however, this chapter does not include sufficient evidence to support such a theory. Chapter 29 on “Stress Technology Medicine,” another chapter which could demonstrate how various systems interact with one another, spends much of its force explaining the theory of autonomic rhythms and laterality (supported by a collection of one-subject experiments). It leaves the reader disappointed, stating that “the credibility of these sophisticated tools” (fascinating yogi relaxation techniques combining breathing and body position) “comes best through their application” without showing any studies demonstrating stress-reducing effects of these relaxation techniques.

In summary, this book is, for the most part, a well-organized contribution to the field of stress research in its cataloging of the latest findings in one accessible work. Unarguably, much of this information is not easily obtained in the standard medical and scientific texts. This volume can be especially helpful to investigators, working with one particular area of stress biology and physiology, who wish to obtain rapid knowledge of other related fields. It may also be of use to physicians and to health personnel who have a strong desire to grasp the complex science underlying stress and its influence on disease. In many ways, such a work may represent one praiseworthy attempt to gather together the current knowledge of mind’s effects and relate it to disparate organ dysfunctions. Yet it is perhaps too much to ask this work to make durable connections between the different research areas and to allow the reader “a look beyond the trees.” More to the point, that flaw may be a reflection on this still unmapped and intertwined field of neurobiology and pathophysiology, and further editions on the subject will no doubt strive to achieve just such a goal.

Stress, the Aging Brain, and the Mechanisms of Neuron Death

Stress, the Aging Brain, and the Mechanisms of Neuron Death

Robert M. Sapolsky

Cambridge, M., The MIT Press, 1992.429 pp

Does stress kill brain cells, and if so, how? In Stress, The Aging Brain, and Mechanisms of Neuronal Death, Dr. Robert Sapolsky presents data supporting the disturbing notion that psychological stresses may be associated with chemical processes in the brain that subject neurons to toxic processes. Dr. Sapolsky’s research, which has taken him from the African veldt to the neurobiology laboratory, provides a framework to orient readers to this interesting review.

In a well-crafted presentation, Dr. Sapolsky integrates his highly original research with related topics of great interest to neuroscientists, neurologists and psychiatrists. He takes care to review hot issues, such as the impact of glucocorticoids on brain function, the role of N-methyl-D-aspartate (NMDA) receptors in learning and neurotoxicity, and the function of nitric oxide as a mediator of NMDA receptor function. In a particularly creative step, Dr. Sapolsky bridges the traditional neuropharmacologic focus on neuro-modulation and the study of energy regulation within neurons during neuromodulation. He presents evidence to support the hypothesis that elevated glucocorticoid levels associated with stress deplete neuronal energy, making them less capable of fending off the toxic effects of inotropic excitatory amino acid receptor stimulation and its associated increase in calcium influx.

As the product of four years of work and “everything (he) knows as of January 10, 1992,” this book contains a prodigious amount of information presented in a thoughtful and user-friendly fashion. It is evident that Dr. Sapolsky has considered challenges facing the reader. Each chapter begins with a review of the book to that point and finishes with a summary of concepts presented within the chapter. These efforts make the text more accessible and enhance its utility as a reference source. In a scientific world dominated by least publishable units and multi-authored texts, Dr. Sapolsky succeeds in developing his views on stress and neurotoxicity in depth with an informal and somewhat socratic style. This stylistic approach makes the large body of information presented more engaging to the reader.

Dr. Sapolsky acknowledges the limitations of his book, occasionally, as they appear in the text. He reviews rapidly evolving fields of research. As a result, significant developments have already occurred in some areas of study reviewed in this book. Also, clinical perspectives on the type of stresses that push neurons “to the brink” could be developed further. The notion that routine social stresses might increase neuronal loss during a seizure is less formidable than the hypothesis that these stresses are neurotoxic in the absence of a medical crisis. One might also have appreciated a more thorough discussion of psychological trauma and its aftermath.

Overall, this is a very good book for researchers in many areas of clinical and basic neurosciences. It serves as a good entry point for researchers and clinicians interested in the areas of stress, neuroactive corticosteroids, excitatory amino acids, and neurotoxicity. Researchers well-versed in these areas may benefit from Dr. Sapolsky’s novel evaluations of a broad range of data and the numerous and intriguing hypotheses presented.