Book reviews A DICTIONARY OF NEUROLOGICAL SIGNS

In the early 1960s a live BBC television broadcast on Parkinson's disease showed the moment of cessation of tremor in a patient undergoing stereotactic surgery. The importance of the physical sign not only in diagnosis but also, together with knowledge of anatomy, in understanding pathophysiology was made clear and a future addiction to physical signs primed in at least one viewer. Subsequent medical school training saw exhaustive exposure. The professorial medical ward round would start in the post mortem room at 1:30 pm, subsequently progressing to the ward, symptoms and signs continuing to be dissected until the medical school bar opened at 6:00 pm. A missed opportunity to examine a patient led to professorial admonishment, permanently recorded in the medical school journal, that `time tide, and signs in the chest wait for no man' but encouragement led to the rare opportunity to observe a patient in circulatory failure, alternately blue, gasping for breath yet pink and quiet 30 seconds later. After undergraduate neurology teaching had combed out much woolly thinking it became possible to appreciate clinical neurology at its pre CT scan peak. Saturday mornings spent, at a cost of 10 shillings each, at the National Hospital, Queen Square, were rewarded not only with masterly case demonstrations but also the opportunity to observe different personalities exhibiting, for example, a gleam of Irish wonder at a case of alexia without agraphia, military planning, precision and clarity, Gielgudian ability to recount the experience of others and, from the merest hints in the history, encourage the patient to divulge diagnostic clues, and humour appreciated both by patients and audience. Apart from any other consideration, the discomfort and risk involved in neuroradiological investigation at that time demanded prior expert assessment. The advent of CT and subsequently MRI scanning inevitably appeared to reduce this need and at the same time exposed some limitations of clinical neurology. For a time it made sense to invest in greater scanning capacity than to increase the number of neurologists. Whereas in the early 1960s Scienti®c American popularised knowledge of the structure of DNA and RNA, and reported the Davson-Danielli lipid bilayer model of the cell membrane, with putative pores, genomes have now been mapped and journals are littered with models of membrane proteins and ion channels, albeit often still reminiscent of Heath Robinson. The corresponding explosion of neurological knowledge over the same period has inevitably led to an increasingly subtle appreciation of history and signs. Further leaps are likely as functional MRI scanning disentangles defects in parallel and interactive processing, perhaps contributing to an understanding of consciousness, and as the neurogenetic web becomes ®ner, perhaps eliminating some current dif®culties in clinical identi®cation of genotype from phenotype. Despite technological advance, it seems likely that professional pride and interest will continue to improve the clinical accuracy of the neurologist in eliciting and interpreting signs, not least to determine the signi®cance of incidental ®ndings and avoid unnecessary or inappropriate treatment. A much more rapid learning curve is demanded than in earlier decades and as a result there is a clear need to simplify reliable access to this knowledge and at the same time provide a comprehensive view of the subject. In my opinion, Larner's book on neurological signs and their meaning achieves this very well, albeit with occasional quali®cations. A great wealth of information has been amassed and collated and often complex topics distilled with consistent clarity. While principally concerned with objective physical signs, subjective symptoms of special anatomical or pathological signi®cance are included, each as a phenomenon of semiological signi®cance. The retentive reader of this book should certainly be able to pursue the active process of seeking information from history and examination in a focused manner for signs that might otherwise be missed, whether more common complaints of urgency of micturition or Lhermitte's phenomenon or rarities such as palinopsia or environmental tilt (though I missed the more common ̄ying saucer syndrome of morning myoclonus). In fact, despite the author's comment that he cannot hope to be comprehensive given the diversity of neurological function, cover is remarkably extensive though concentration on more esoteric aspects has left rare gaps. Dropped head syndrome is included but not waddling gait or relative preservation of abdominal re ̄exes in familial spastic paraparesis. Several eponyms are attached to lid retraction but fear is not mentioned. Given the inclusion of De Musset's sign of head tremor secondary to aortic valve regurgitation, the deliberate omission of `bruit' (whether carotid, cranial or spinal) might perhaps be reversed in future editions. Primary dermatological conditions of neurological relevance are not included but itching, goose pimples, oedema, and cyanosis, of neurogenic origin, might be considered, together with pallor or facial ̄ushing that may accompany migraine or migrainous neuralgia respectively, or partial seizures. Given the