Preface to the Fifth Edition

 These are exciting times. Amazing advances in imaging, genetics, immunology, pharmacology, and drug-delivery systems, and new technological  approaches in the operating room and intensive care unit have transformed the practice of medicine in the 25 years since this book was first published. Spectacular progress is continuing to occur in the medical sciences—for example, in molecular biology at the level of genes, proteins, and ion channels, and in the development of animal models of disease—and, over the next few years, will further impact clinical practice. These advances will undoubtedly lead to a new systematic approach to clinical medicine that should complement, rather than replace, the traditional approach. It has been suggested that the eventual availability of, for example, a simple genetic test or cheap imaging technique may sometimes make clinical consultation redundant. Such statements give cause for concern. Clinical consultations provide much more than a diagnostic label or a means to define a course of action. The interaction that occurs between patients and physicians during the course of the clinical encounter helps to establish a professional relationship that allows patients to receive optimal and multidimensional care. This interaction leads to suggestions about the diagnosis, determines whether ancillary studies are required and aids their interpretation in context, permits advice on treatment based on the individual clinical and psychosocial background, guides prognostication, and ensures that patients are both informed and educated about their disease. It also provides physicians with the opportunity—increasingly neglected—to think about the clinical problem posed by individual patients. It is therefore unfortunate that technological advances—wonderful as they may be—are tending to dehumanize clinical medicine and erode clinical skills and common sense.

There are other issues that are emerging with regard to the practice of medicine. Therapeutic and management options are in some cases too unrestrained and in other instances curtailed unnecessarily by market forces and practitioners of evidence-based medicine. Physicians should practice medicine in such a way that decisions are based on the best available evidence, but the absence of evidence for an effect is not evidence for the absence of an effect. Clinical medicine is not always the exact science that some pretend it to be, and its practice remains both an art and a science. It is important that physicians keep this in mind and remain committed to the welfare of their patients rather than some abstract concept. It is my hope that these values are reflected in the pages of this volume.

The general acceptance of earlier editions of this book and the changes occurring in the field have prompted the development of this new—fifth— edition, aimed at all clinicians but especially neurologists, internists, hospitalists, and primary health-care providers. The aim remains the same as that of previous editions, namely to define both the neurologic aspects of general medical disorders and the general medical and other aspects of various neurologic diseases. The book therefore provides an account of clinical neurology from a different perspective than most other textbooks, and serves as an interface between neurology and the other medical specialties. This is important because all physicians—including neurologists—must retain some expertise in general medicine to best serve the interests of their patients. Neurologic disorders are not encountered in isolation but occur in patients who often have or will develop other medical problems, and many general medical disorders have neurologic complications or manifest as diseases of the central or peripheral nervous system.

Physicians need to keep abreast of advances in the field, but the pace of change, the daunting size and complicated jargon of the medical literature, the need to optimize the use of limited resources, and the increasing administrative and bureaucratic demands on their time have made it difficult for them to do so. Changing market forces and health-care delivery systems have added to the problem. At the same time, communication among or even among  within the same overall specialty is becoming increasingly stilted, even as a lack of consensus exists among physicians concerning the appropriate extent of specialist involvement in the care of patients with neurologic manifestations of disease. This underlines the need to coordinate patient care and ensure not only that neurologists have some understanding of the general medical issues relating to their patients but that internists, family practitioners, and other physicians, in turn, have some understanding of neurologic disorders.

This book, then, is aimed at both general physicians and neurologists, regardless of their level of training or experience. It is intended to serve as a guide to junior physicians who need experience to nurture their developing skills and then follow the path of lifelong learning to maintain them. More senior practitioners may also find this volume useful as a source of reference, as a means of keeping abreast of developments in the field, and thus as a guide to the evolving standards of care of patients with diseases that may already be familiar to them.

I am delighted that Dr. S. Andrew Josephson has joined me as co-editor of this new edition. He is a friend, colleague, and a board-certified neurologist who is widely recognized both nationally and internationally for his clinical expertise, encyclopedic knowledge, teaching skills, and clinical scholarship. One of his many achievements has been in helping to establish neuron hospital list medicine as a distinct branch of medicine in the United States. Preparing this new volume with him has been an especially enjoyable experience. As with earlier editions, this new one has been crafted to reflect the changing face of the subject but—at the same time—we have attempted to limit its size so that it does not become too intimidating. We have also limited the bibliography of individual chapters to references published only recently and at most within the last 25 years, whenever possible. Older references have been retained only when they involve classic papers or provide seminal descriptions of diseases, clinical phenomena, or specific treatments. More detailed reference to the older literature can be found in earlier editions of the book.

New chapters have been added "and" existing ones expanded to cover changes that have occurred in recent years. The volume has evolved from its original black-and-white format to a two-color work, and now goes into full color. This will enhance its appearance and will, I hope, add to the utility of its illustrations. The book is published electronically as well as in a print format. The electronic version should make it more accessible, facilitate searches for specific information, and be attractive to younger readers.

This book has particular meaning to me. The first edition was published exactly a quarter-century ago, at a time when my three children were either in grade school or pre-school, and their fun and laughter helped to revitalize me when my work as an author or editor seemed a little overwhelming. Now they have gone their separate ways, and I follow their careers with enormous pleasure. Alexandra, a pediatrician, is just finishing a 3-year fellowship in pediatric rheumatology at the Children’s Hospital of Seattle, and I envy her up-to-date knowledge of medicine. Jonathan is a federal defense attorney in Los Angeles,  I am proud of his wish to serve those who are unable to help themselves. Anthony, our youngest and another lawyer, is an assistant district attorney in the office of the Manhattan District Attorney in New York, and I marvel at the prudent and judicious way in which he approaches his work. During the production of the second edition of Neurology and General Medicine, my father—a wonderful man—died unexpectedly, and I dedicated the book to him. I have continued to dedicate subsequent volumes to his memory, for I think of him often. My wife, Jan, has always given me the support, encouragement, and time that I need to complete my writing projects, and takes on many additional chores without even mentioning them in order to ease my burden. I cannot thank her enough.

Many of the authors of individual chapters have contributed to the book since the first edition appeared in 1989; others are more recent contributors. I am grateful to them for their help in making the volume an important part of the medical literature. In preparing this new edition, some authors from the last edition were replaced because they had retired or were in ill-health, and I thank them for their past contributions and wish them well. Dr. Josephson and I are grateful to all the contributors to this new edition. They were generous with their time and in sharing their knowledge, were tolerant of our requests, and worked hard to update their chapters from the last edition or—in the case of new authors—to review developments in their own particular field of interest. Some, illustrations in the book are taken from previously published sources, as is acknowledged in the text, and we are grateful for permission to reproduce them here. Finally, we are grateful to a number of people at Elsevier, our publisher, for their help and especially to Mr. Thomas E. Stone and Ms. Kristi Anderson for their unfailing assistance in the development of this book, to Mr. Roger south wick for his careful copy-editing, and to Ms. Julia Haynes for seeing the volume through the production process. They were a wonderful team with whom it was a pleasure to work.

 Preface to the First Edition

 The increasing sophistication and complexity of modern medicine have led to greater specialization among practitioners and to more restricted communication between physicians in  differently disciplines. Perhaps, inevitably, this trend has created certain major problems. These particularly well exemplar by the relationship between neurology and general medicine.

For non-neurologists, evaluation of patients with neurological symptoms and signs has always because of the complexity of the anatomy and physiology of the nervous system and frustrating because the therapeutic options have seemed somewhat limited. Nevertheless, a number of neurological diseases are exacerbated by, or occur as complications of, general medical disorders. Appropriate management of these neurological disturbances requires their early recognition and an appreciation of their prognosis. It is equally important to recognize the manner in which such neurological disorders may management of the primary or coexisting medical condition, as well as the manner in which systemic complications of neurological disorders may require somewhat different management than when these complications occur in other settings.

For neurologists, who are being asked increasingly to evaluate neurological disturbances presenting in the context of other medical disorders, the is equally apparent. The general background of cases is frequently confusing, the relationship of the neurological to the other medical problems is commonly not appreciated, and the manner in which treatment needs to be “tailored” to the  clinical context is often not clear. Furthermore, neurological disturbances may themselves be the presenting feature of general medical disorders or lead to general medical complications requiring speedy recognition and effective management.

I hope that the present volume will appeal to both neurologists and physicians in other specialties by providing a guide to the neurological aspects of general medical disorders and to medical complications of certain neurological diseases. It is not intended to be a textbook of neurology, but rather a “bridge” between neurology and the other medical specialties.

It is a pleasure to acknowledge the help that I received from various people in developing this book. I am grateful to the various contributors, who devoted a great deal of time and energy to reviewing developments in their own  of interest and showed considerable tolerance of the many demands that I made upon them. I am grateful also to Mr. Robert Hurley and Ms. Margot Otway at Churchill Livingstone for their help and advice during the preparation of this book. Finally, the support and encouragement of my wife, Jan, and of our children, Alexandra, Jonathan, and Anthony, did much to ease the burden involved in seeing this volume to its conclusion.