- Email: [email protected]
Finding a voice
DISSECTING ROOM
The Refractory Finding a voice “Learn to labour and to wait.” Longfellow (1807–82)
he art and discipline of fugue came to perfection in Johann Sebastian Bach’s 48 preludes and fugues. W R Anderson said that fugue is a style rather than a form— one that is extremely free. The fugue might provide a model for other complex activities in which individual parts, with different pitch and strength of voice, come together with a defined aim and conclude with all voices in complete balance and harmony, making a unified statement at the finale. Large, collaboratively undertaken clinical trials might well use the art and discipline of fugue as an inspiring and beneficial model. Anderson also said that the essence of fugue is organic growth out of small material—much as a complicated protocol will grow out of an imaginative hypothesis scrawled on the back of an envelope. With respect to its free style, Anderson said: “As so
T
often in life, when we seem to be most free we have most responsibility.” In a fugue, different voices present the same subject, or double subject, and counter-subject, in ordered sequence, to a prescribed rhythm and pace. If the performers are disciplined listeners, competent, and do not lose their nerve, their independent contrapuntal voices combine harmoniously, building as they go, concluding with a broad rallentando, gloriously in time at the right time for composer, performer, and listener. The subject of the fugue may be presented by voices following the first voice, or in augmentation (doubling the time taken for the melody), or in diminution (halving the timing of the melody), or in inversion (turning it upside down). All these voices are compatible at every
A superior guide to seizures Seizures: Medical Causes and Management Norman Delanty, ed. Totowa, NJ: Humana Press, 2001. Pp 384. $125.00. ISBN 0896038270.
moment; if the subject is right, the structure is respected, and nobody falters or steps out of line. Today, pharmaceutical industrial trialists’ voices dominate clinical trials, dictating the pace, silencing those with important counter-subjects, and bruiting abroad premature, incomplete statements. This approach results in an unacceptable and discordant cacophony. Has medicine lost its voice? Will it not speak out before coercive healthism, commercially driven in enormous prevention trials, makes patients of us all? Hope must rest with the latest entrant, the patient-researcher, to restore proper tempo, balance, and harmony. Finding their voice, they will give faltering medicine confidence to sing out. Today, there is a critical global audience to satisfy by this interdependent performance without a conductor. Refractor e-mail: [email protected]
with unexplained fevers, but no other evidence of an allergic reaction. Coeliac sprue is one of the few diseases not discussed, although there is some interesting published work on antigliadin antibodies and occipital seizures. A chapter on herbal or alternative medications may be a nice addition in the future, including interactions with antiepileptic drugs and the potential for causing or worsening seizures. Although not a major shortcoming, there is some overlap between chapters, including two separate protocols for treatment of status epilepticus in two consecutive chapters. I am not aware of another textbook of this size that covers this breadth of topics related to seizures in systemic illnesses. Although not intended for epileptologists, this book will be a valuable resource for all neurologists who undertake frequent hospital consultations, and for all physicians who deal with the multitude of medical conditions that can cause acute symptomatic seizures. This is an excellent book to keep available in emergency rooms, intensive care units, hospital wards, and almost every physician’s office. I look forward to future editions.
orman Delanty has managed cardiologists, specialists in infectious to find a hole in the world of diseases, and pharmacists. seizure-related books, and has There is some room for improvement, filled it. Seizures: Medical Causes and as with all first editions. The chapter on Management explores the many features distinguishing between syncope and of seizures that occur in relation to seizures, for example, does not discuss medical illnesses. Topics covered the relative frequency of incontinence include seizures related to renal failure, or tongue biting, but is a very useful hepatic failure, organ transplant, use of chapter nonetheless. I would have liked alcohol, and malignant disease, as well a discussion on the commonly encounas drug use and misuse. There are also tered scenario of a patient on phenytoin chapters on miscellaneous illnesses that can cause seizures, such as vasculitides, mitochondrial syndromes, sarcoidosis, and porphyria. The strength of this book is the well organised and clinically useful discussions of seizures in each of the above settings that will be useful for practitioners from many different specialties. In addition, there is ample coverage of proposed pathophysiologies, including a separate chapter devoted to this topic. The contributors are respected experts from the USA, Ireland, Brazil, and Sri Lanka. Most of the contributors are Shaun Caton Diapason neurologists, but there are also emergency medicine physicians,
N
2044
Lawrence J Hirsch e-mail: [email protected]
THE LANCET • Vol 359 • June 8, 2002 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.
The Refractory Finding a voice “Learn to labour and to wait.” Longfellow (1807–82)
he art and discipline of fugue came to perfection in Johann Sebastian Bach’s 48 preludes and fugues. W R Anderson said that fugue is a style rather than a form— one that is extremely free. The fugue might provide a model for other complex activities in which individual parts, with different pitch and strength of voice, come together with a defined aim and conclude with all voices in complete balance and harmony, making a unified statement at the finale. Large, collaboratively undertaken clinical trials might well use the art and discipline of fugue as an inspiring and beneficial model. Anderson also said that the essence of fugue is organic growth out of small material—much as a complicated protocol will grow out of an imaginative hypothesis scrawled on the back of an envelope. With respect to its free style, Anderson said: “As so
T
often in life, when we seem to be most free we have most responsibility.” In a fugue, different voices present the same subject, or double subject, and counter-subject, in ordered sequence, to a prescribed rhythm and pace. If the performers are disciplined listeners, competent, and do not lose their nerve, their independent contrapuntal voices combine harmoniously, building as they go, concluding with a broad rallentando, gloriously in time at the right time for composer, performer, and listener. The subject of the fugue may be presented by voices following the first voice, or in augmentation (doubling the time taken for the melody), or in diminution (halving the timing of the melody), or in inversion (turning it upside down). All these voices are compatible at every
A superior guide to seizures Seizures: Medical Causes and Management Norman Delanty, ed. Totowa, NJ: Humana Press, 2001. Pp 384. $125.00. ISBN 0896038270.
moment; if the subject is right, the structure is respected, and nobody falters or steps out of line. Today, pharmaceutical industrial trialists’ voices dominate clinical trials, dictating the pace, silencing those with important counter-subjects, and bruiting abroad premature, incomplete statements. This approach results in an unacceptable and discordant cacophony. Has medicine lost its voice? Will it not speak out before coercive healthism, commercially driven in enormous prevention trials, makes patients of us all? Hope must rest with the latest entrant, the patient-researcher, to restore proper tempo, balance, and harmony. Finding their voice, they will give faltering medicine confidence to sing out. Today, there is a critical global audience to satisfy by this interdependent performance without a conductor. Refractor e-mail: [email protected]
with unexplained fevers, but no other evidence of an allergic reaction. Coeliac sprue is one of the few diseases not discussed, although there is some interesting published work on antigliadin antibodies and occipital seizures. A chapter on herbal or alternative medications may be a nice addition in the future, including interactions with antiepileptic drugs and the potential for causing or worsening seizures. Although not a major shortcoming, there is some overlap between chapters, including two separate protocols for treatment of status epilepticus in two consecutive chapters. I am not aware of another textbook of this size that covers this breadth of topics related to seizures in systemic illnesses. Although not intended for epileptologists, this book will be a valuable resource for all neurologists who undertake frequent hospital consultations, and for all physicians who deal with the multitude of medical conditions that can cause acute symptomatic seizures. This is an excellent book to keep available in emergency rooms, intensive care units, hospital wards, and almost every physician’s office. I look forward to future editions.
orman Delanty has managed cardiologists, specialists in infectious to find a hole in the world of diseases, and pharmacists. seizure-related books, and has There is some room for improvement, filled it. Seizures: Medical Causes and as with all first editions. The chapter on Management explores the many features distinguishing between syncope and of seizures that occur in relation to seizures, for example, does not discuss medical illnesses. Topics covered the relative frequency of incontinence include seizures related to renal failure, or tongue biting, but is a very useful hepatic failure, organ transplant, use of chapter nonetheless. I would have liked alcohol, and malignant disease, as well a discussion on the commonly encounas drug use and misuse. There are also tered scenario of a patient on phenytoin chapters on miscellaneous illnesses that can cause seizures, such as vasculitides, mitochondrial syndromes, sarcoidosis, and porphyria. The strength of this book is the well organised and clinically useful discussions of seizures in each of the above settings that will be useful for practitioners from many different specialties. In addition, there is ample coverage of proposed pathophysiologies, including a separate chapter devoted to this topic. The contributors are respected experts from the USA, Ireland, Brazil, and Sri Lanka. Most of the contributors are Shaun Caton Diapason neurologists, but there are also emergency medicine physicians,
N
2044
Lawrence J Hirsch e-mail: [email protected]
THE LANCET • Vol 359 • June 8, 2002 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.