- Email: [email protected]
A clear vision of neuro-ophthalmology
DISSECTING ROOM
The Refractory Attitude “The fear of death often proves mortal.” Joseph Addison
ou’ve got an attitude problem!” was a catch-phrase laughingly bandied about by my son when an undergraduate. We found it useful too. A useful put-down no doubt, but when thought rather than uttered, a useful personal prompt for anyone trying to understand people’s unexpected reactions, or to prevent utterance of an unnecessary comment, criticism, or apology. “Don’t apologise!” was another of his favourites: not an absolute rule, but quite useful when used judiciously. It was a new notion for parents brought up in a different era to be over-polite, non-confrontational, and uncomplaining. It is good for the complacency of elders to be challenged by the inheritors of this world. An individual’s attitude to disease seems to have an effect on its outcome. For example, patients with cancer are known to adopt various coping
Y
“
strategies, loosely divided into a range of blunting and monitoring styles. Simplistically, the blunters’ attitude to information is not to hear, not to integrate, not to seek it. Some patients prefer to cope by denying the reality of their life-threatening diagnosis. Who is to deny that living in the present is the most satisfactory way of coping with any disaster, by not allowing it to disrupt the pleasure and familiarity of ordinary routine daily existence, to live each day as it comes, in hope, not fear, to the very best of one’s ability? Monitors may also do this, but adopt the opposite attitude of listening, integrating, and seeking to understand. Psychological research suggests that the coping style of confronting and action-taking may result in improved psychological and biological outcomes.
A clear vision of neuro-ophthalmology The Neurology of Vision Jonathan D Trobe. New York: Oxford University Press, 2001. Pp 470. $120.00. ISBN 0195129784. o be a worthwhile addition in the growing list of books about neuro-ophthalmology, a new textbook should have a Boy Scout’s list of virtues. It should be authoritative, complete without being encyclopaedic, readable, well referenced, well indexed, and should have, in the words of William Fletcher Hoyt, “new ways of looking at things”—new illustrations. Jonathan Trobe succeeds on all of these points in the latest volume of the Contemporary Neurology Series, entitled The Neurology of Vision. This text neatly complements volume 55 of the same series by R John Leigh and David Zee entitled The Neurology of Eye Movements, which is now a classic and in its third edition. Trobe was a journalist in a former life, during which he developed a clear, concise writing style. He is both an ophthalmologist and neurologist and was a professor of ophthalmology before taking his neurology training. He brings real authority to this single-authored text. Trobe systematically attends to the limited understanding of ophthalmology that is inherent in neurological training,
T
1822
thus making the parts of the text that deal with ophthalmology easier to understand. The text is up-to-date and thoughtfully referenced. The index is especially well done, which makes the book easily usable for the tiro as well as the old hand. He incorporates algorithms for dealing with standard clinical disorders and has instructional boxes that summarise and encapsulate especially important clinical points. He clearly explains the interpretation of the Humphrey static visual field that has largely replaced Goldmann perimetry. The appearance of this new form of visual field test has left most neurologists out in the cold and he rectifies this deficit. The illustrations are well chosen, logically placed, and each stands on its own with complete captions in almost all cases. The colour photographs are aptly chosen and beautifully reproduced. Some of them could have had more extensive captions and many could have been printed larger. The only quibble I have is that the photographs are almost idealised examples of diseases at a magnification that cannot be achieved with a
Societal attitudes to health and disease are reflected in countries’ differing social health policies, but are not prosperity-related. It is chilling to realise that in the USA, African-American men and women, as a group, have a lower chance of reaching old age than poorer men and women in the state of Kerala, India. Thorough analysis reveals that it is the attitude to public health and poverty as evidenced in a country’s public-health policies, irrespective of the their degree of wealth, that has an effect on public health, public education, longevity, and general health. Resources spent on social engineering would have a greater effect in terms of numbers of lives extended and improved, as opposed to moredeveloped nations’ pursuit of expensive life-extension measures, often of poor quality, in chronic and terminal diseases. Finding the fulcrum is the global health challenge. Refractor e-mail: [email protected]
direct ophthalmoscope. Thus, what the clinician sees in the colour atlas in the book is not what he sees when he looks into the eye with his ophthalmoscope. This is a problem with fundus illustrations, since there is limited space for coloured photographs and many of the examples of pathological retinal conditions do not occur in close proximity to the optic disc, which is the structure most neurologists aim at. The black and white illustrations, that elucidate the blood supply to visual areas of the brain and complement the description of various syndromes caused by infarction, are newly drawn and are supplemented by excellent CT scan and MRI examples. This section is helpful to the ophthalmologist for whom the neuroanatomy might otherwise be opaque. The cartoons are also excellent —they deal with disc swelling, glaucoma, and macular disease making these ophthalmic clinical issues clearer for the neurologist. In his chapter on non-organic visual loss, Trobe lucidly explains the techniques for identifying such visual loss, and what to do to help these challenging patients. Finally, to be special, a book should have some unique feature. This is found at the end of Trobe’s book where there are 32 questions and answers on common neuro-ophthalmic disorders. These ticklers challenge the reader to
THE LANCET • Vol 358 • November 24, 2001
For personal use. Only reproduce with permission from The Lancet Publishing Group.
DISSECTING ROOM
recall the material he or she has just read. The answers are included in a medical knowledge self-assessment format that provides an explanation of each foil, why it is correct or incorrect, and a page citation for each question. The chapters on symptoms of optical disorders, negative and positive symptoms, and testing of visual acuity and other psychophysical phenomena, are especially valuable to the neurologist whose training only briefly deals with these issues. For this reason this textbook is well suited to the neurologist, neurosurgeon, and ophthalmologist both in training and in practice, because of the clarity Trobe brings to understanding the origin of optical symptoms that masquerade as neurological disease. This feature is the virtue of having a single author who has come at neuro-ophthalmological disorders from both vantage points. I highly recommend this volume by itself as an excellent introduction to neuro-ophthalmology of the afferent visual pathways or as the afferent half of the pair of neuro-ophthalmological texts that are available in this Oxford series. It is superb and should be available in the clinic for quick reference, and in the library for more leisurely perusal.
Walk on the wild side Wilderness Medicine, 4th Edition Paul S Auerbach. St Louis: Mosby, 2001. Book: Pp 1904, $199.00, ISBN 0323009506 . CD-ROM: $199.00, ISBN 032301674X.
y chance this book arrived on my desk as I was about to start teaching a 2-week course in wilderness emergency medicine. It is run as an option in the penultimate year of our local undergraduate medical school course. In the first week, a purely classroom-based programme focuses on key wilderness topics, such as thermal emergencies, wound management, and envenomation. An emphasis is placed on practical skills, landmark published work, and how to apply the principles of medicine in an environment where technology and further support will be limited. In the second week, we embark on a wilderness journey where scenarios such as near drowning while white-water rafting or major trauma while bushwalking are played out with the students acting as victims and rescuers. A key feature of the course is that it is cotaught with a group of experienced outdoor educators who contribute their substantial leadership, improvisation, and bushcraft skills, while the medical James J Corbett students impart their medical knowlDepartment of Neurology, University of edge. Our course highlights what Mississippi Medical Center, Jackson, makes wilderness medicine unique: MS 39216–4505, USA it is medicine practised by a range of providers rather than just doctors, where improvisation and pragmatism must often take precedence over technology and gold standard care. Wilderness medicine can be said to be medicine stripped bare to its basic principles. For the same reasons, Paul Auerbach’s Wilderness Medicine, 4th Edition is not your typical medical textbook. Alongside chapters written as a definitive statement by world authorities on such subjects as hypothermia or altitude illness, are chapters on topics as diverse as clothing for the outdoors, survival This Portrait of Margherita Gonzaga (1438–41) is one of the skills, and wilderexhibits at Pisanello: Painter to the Renaissance Court, at the ness improvisation. National Gallery, London, UK, showing until Jan 13, 2002. The inclusion of Musée du Louvre, Paris/Photo RMN
B
THE LANCET • Vol 358 • November 24, 2001
these sorts of subjects is what makes this book so special. You might not like the idea of using a safety pin through the lip to keep the tongue of an unconscious patient from obstructing the airway, but this may be one of the few practical options available to a wilderness medical provider who needs to focus his energies on rescue and his own safety in a remote setting. You can always find things to criticise in a large multiauthored book such as this. There is a strong north American bias in the authorship. Although serious efforts have been made to address this bias by covering such topics as snake and spider bites, in other parts of the book we still see authors using pints and ounces or offering medicolegal advice that may not apply across the world. There are other issues that I would have liked to have seen given even more coverage, for example, the use of local and regional anaesthesia, and wound care alternatives such as staples and tissue glues. These issues are very practical ones for anyone providing medical care on a lengthy wilderness trip. Nonmedical readers of this text would, I am sure, appreciate greater coverage of the management of major medical emergencies in the wilderness, such as acute coronary syndromes, asthma, seizures, stroke, and poisoning. More so because age or infirmity are no longer seen as the barriers to a wilderness experience that they once were. The availability of the full book on CD-ROM serves to further strengthen its value. The CD-ROM is easy to install with the many excellent pictures and diagrams that allow ideas and procedures to be conveyed easily, even to the nonmedical reader. The ability to link directly to indexed abstracts available on PubMed or to access relevant websites shows the strengths of an electronic format and how hard copy and electronic versions can serve different but complementary roles. This work sets out to be a comprehensive and definitive textbook—it succeeds. Even if your wilderness is an urban one, this is a great read and an invaluable resource. Ian Rogers Emergency Department, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, WA 6009, Australia
1823
For personal use. Only reproduce with permission from The Lancet Publishing Group.
The Refractory Attitude “The fear of death often proves mortal.” Joseph Addison
ou’ve got an attitude problem!” was a catch-phrase laughingly bandied about by my son when an undergraduate. We found it useful too. A useful put-down no doubt, but when thought rather than uttered, a useful personal prompt for anyone trying to understand people’s unexpected reactions, or to prevent utterance of an unnecessary comment, criticism, or apology. “Don’t apologise!” was another of his favourites: not an absolute rule, but quite useful when used judiciously. It was a new notion for parents brought up in a different era to be over-polite, non-confrontational, and uncomplaining. It is good for the complacency of elders to be challenged by the inheritors of this world. An individual’s attitude to disease seems to have an effect on its outcome. For example, patients with cancer are known to adopt various coping
Y
“
strategies, loosely divided into a range of blunting and monitoring styles. Simplistically, the blunters’ attitude to information is not to hear, not to integrate, not to seek it. Some patients prefer to cope by denying the reality of their life-threatening diagnosis. Who is to deny that living in the present is the most satisfactory way of coping with any disaster, by not allowing it to disrupt the pleasure and familiarity of ordinary routine daily existence, to live each day as it comes, in hope, not fear, to the very best of one’s ability? Monitors may also do this, but adopt the opposite attitude of listening, integrating, and seeking to understand. Psychological research suggests that the coping style of confronting and action-taking may result in improved psychological and biological outcomes.
A clear vision of neuro-ophthalmology The Neurology of Vision Jonathan D Trobe. New York: Oxford University Press, 2001. Pp 470. $120.00. ISBN 0195129784. o be a worthwhile addition in the growing list of books about neuro-ophthalmology, a new textbook should have a Boy Scout’s list of virtues. It should be authoritative, complete without being encyclopaedic, readable, well referenced, well indexed, and should have, in the words of William Fletcher Hoyt, “new ways of looking at things”—new illustrations. Jonathan Trobe succeeds on all of these points in the latest volume of the Contemporary Neurology Series, entitled The Neurology of Vision. This text neatly complements volume 55 of the same series by R John Leigh and David Zee entitled The Neurology of Eye Movements, which is now a classic and in its third edition. Trobe was a journalist in a former life, during which he developed a clear, concise writing style. He is both an ophthalmologist and neurologist and was a professor of ophthalmology before taking his neurology training. He brings real authority to this single-authored text. Trobe systematically attends to the limited understanding of ophthalmology that is inherent in neurological training,
T
1822
thus making the parts of the text that deal with ophthalmology easier to understand. The text is up-to-date and thoughtfully referenced. The index is especially well done, which makes the book easily usable for the tiro as well as the old hand. He incorporates algorithms for dealing with standard clinical disorders and has instructional boxes that summarise and encapsulate especially important clinical points. He clearly explains the interpretation of the Humphrey static visual field that has largely replaced Goldmann perimetry. The appearance of this new form of visual field test has left most neurologists out in the cold and he rectifies this deficit. The illustrations are well chosen, logically placed, and each stands on its own with complete captions in almost all cases. The colour photographs are aptly chosen and beautifully reproduced. Some of them could have had more extensive captions and many could have been printed larger. The only quibble I have is that the photographs are almost idealised examples of diseases at a magnification that cannot be achieved with a
Societal attitudes to health and disease are reflected in countries’ differing social health policies, but are not prosperity-related. It is chilling to realise that in the USA, African-American men and women, as a group, have a lower chance of reaching old age than poorer men and women in the state of Kerala, India. Thorough analysis reveals that it is the attitude to public health and poverty as evidenced in a country’s public-health policies, irrespective of the their degree of wealth, that has an effect on public health, public education, longevity, and general health. Resources spent on social engineering would have a greater effect in terms of numbers of lives extended and improved, as opposed to moredeveloped nations’ pursuit of expensive life-extension measures, often of poor quality, in chronic and terminal diseases. Finding the fulcrum is the global health challenge. Refractor e-mail: [email protected]
direct ophthalmoscope. Thus, what the clinician sees in the colour atlas in the book is not what he sees when he looks into the eye with his ophthalmoscope. This is a problem with fundus illustrations, since there is limited space for coloured photographs and many of the examples of pathological retinal conditions do not occur in close proximity to the optic disc, which is the structure most neurologists aim at. The black and white illustrations, that elucidate the blood supply to visual areas of the brain and complement the description of various syndromes caused by infarction, are newly drawn and are supplemented by excellent CT scan and MRI examples. This section is helpful to the ophthalmologist for whom the neuroanatomy might otherwise be opaque. The cartoons are also excellent —they deal with disc swelling, glaucoma, and macular disease making these ophthalmic clinical issues clearer for the neurologist. In his chapter on non-organic visual loss, Trobe lucidly explains the techniques for identifying such visual loss, and what to do to help these challenging patients. Finally, to be special, a book should have some unique feature. This is found at the end of Trobe’s book where there are 32 questions and answers on common neuro-ophthalmic disorders. These ticklers challenge the reader to
THE LANCET • Vol 358 • November 24, 2001
For personal use. Only reproduce with permission from The Lancet Publishing Group.
DISSECTING ROOM
recall the material he or she has just read. The answers are included in a medical knowledge self-assessment format that provides an explanation of each foil, why it is correct or incorrect, and a page citation for each question. The chapters on symptoms of optical disorders, negative and positive symptoms, and testing of visual acuity and other psychophysical phenomena, are especially valuable to the neurologist whose training only briefly deals with these issues. For this reason this textbook is well suited to the neurologist, neurosurgeon, and ophthalmologist both in training and in practice, because of the clarity Trobe brings to understanding the origin of optical symptoms that masquerade as neurological disease. This feature is the virtue of having a single author who has come at neuro-ophthalmological disorders from both vantage points. I highly recommend this volume by itself as an excellent introduction to neuro-ophthalmology of the afferent visual pathways or as the afferent half of the pair of neuro-ophthalmological texts that are available in this Oxford series. It is superb and should be available in the clinic for quick reference, and in the library for more leisurely perusal.
Walk on the wild side Wilderness Medicine, 4th Edition Paul S Auerbach. St Louis: Mosby, 2001. Book: Pp 1904, $199.00, ISBN 0323009506 . CD-ROM: $199.00, ISBN 032301674X.
y chance this book arrived on my desk as I was about to start teaching a 2-week course in wilderness emergency medicine. It is run as an option in the penultimate year of our local undergraduate medical school course. In the first week, a purely classroom-based programme focuses on key wilderness topics, such as thermal emergencies, wound management, and envenomation. An emphasis is placed on practical skills, landmark published work, and how to apply the principles of medicine in an environment where technology and further support will be limited. In the second week, we embark on a wilderness journey where scenarios such as near drowning while white-water rafting or major trauma while bushwalking are played out with the students acting as victims and rescuers. A key feature of the course is that it is cotaught with a group of experienced outdoor educators who contribute their substantial leadership, improvisation, and bushcraft skills, while the medical James J Corbett students impart their medical knowlDepartment of Neurology, University of edge. Our course highlights what Mississippi Medical Center, Jackson, makes wilderness medicine unique: MS 39216–4505, USA it is medicine practised by a range of providers rather than just doctors, where improvisation and pragmatism must often take precedence over technology and gold standard care. Wilderness medicine can be said to be medicine stripped bare to its basic principles. For the same reasons, Paul Auerbach’s Wilderness Medicine, 4th Edition is not your typical medical textbook. Alongside chapters written as a definitive statement by world authorities on such subjects as hypothermia or altitude illness, are chapters on topics as diverse as clothing for the outdoors, survival This Portrait of Margherita Gonzaga (1438–41) is one of the skills, and wilderexhibits at Pisanello: Painter to the Renaissance Court, at the ness improvisation. National Gallery, London, UK, showing until Jan 13, 2002. The inclusion of Musée du Louvre, Paris/Photo RMN
B
THE LANCET • Vol 358 • November 24, 2001
these sorts of subjects is what makes this book so special. You might not like the idea of using a safety pin through the lip to keep the tongue of an unconscious patient from obstructing the airway, but this may be one of the few practical options available to a wilderness medical provider who needs to focus his energies on rescue and his own safety in a remote setting. You can always find things to criticise in a large multiauthored book such as this. There is a strong north American bias in the authorship. Although serious efforts have been made to address this bias by covering such topics as snake and spider bites, in other parts of the book we still see authors using pints and ounces or offering medicolegal advice that may not apply across the world. There are other issues that I would have liked to have seen given even more coverage, for example, the use of local and regional anaesthesia, and wound care alternatives such as staples and tissue glues. These issues are very practical ones for anyone providing medical care on a lengthy wilderness trip. Nonmedical readers of this text would, I am sure, appreciate greater coverage of the management of major medical emergencies in the wilderness, such as acute coronary syndromes, asthma, seizures, stroke, and poisoning. More so because age or infirmity are no longer seen as the barriers to a wilderness experience that they once were. The availability of the full book on CD-ROM serves to further strengthen its value. The CD-ROM is easy to install with the many excellent pictures and diagrams that allow ideas and procedures to be conveyed easily, even to the nonmedical reader. The ability to link directly to indexed abstracts available on PubMed or to access relevant websites shows the strengths of an electronic format and how hard copy and electronic versions can serve different but complementary roles. This work sets out to be a comprehensive and definitive textbook—it succeeds. Even if your wilderness is an urban one, this is a great read and an invaluable resource. Ian Rogers Emergency Department, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, WA 6009, Australia
1823
For personal use. Only reproduce with permission from The Lancet Publishing Group.