Author: Adam Zeman
How do you sketch a vivid profile of the most perplexing organ in the body? How do you portray the intricate workings of what is, ‘by a very long way, the most complex entity we have yet encountered in the universe‘? (page 36). The author of this book, a clinical and academic neurologist, achieved this by adopting an ingenious ‘level by level‘ approach, applying his brush strokes in layers, ‘from atom to psyche‘ (page ix). He used compelling neurological disorders as his palette; illustrative clinical vignettes as his canvas; and scientific and historical facts as his easel. With a final dabbing of appropriate references from literature and the arts, the end result is a mosaic of a sophisticated structure which generally works flawlessly…but occasionally breaks down unpredictably.
To demonstrate the myriad of disorders that afflict the brain, the book employed several compelling case presentations. A typical example is the author’s patient whose ecstatic seizures start with a ‘slight familiar churning in the stomach’, which then proceeds to a ‘transfiguration’ during which he becomes ‘weightless, an angel on the wing, soaring through a landscape fraught with significance…’ (page 83). Another is his patient with choreoathetosis, who, unable to stay still, carries out bizarre involuntary movements such as ‘dancing a jig‘ (page 26). Another illustrative example is the author’s patient with dementia which predominantly affected the left hemisphere; this enabled the now unrestrained right hemisphere to erupt in life with an unexpected ‘flowering of artistic talent‘ (pages 241-155). The author complemented these case studies with detailed explanations of the faulty mechanisms underlying diverse neurological syndromes. An example is narcolepsy, a disorder resulting from a ‘breakdown of the boundaries of sleep and wakefulness‘ or the brain’s failure to ‘segregate the states of consciousness‘ (pages 108-109).
Evident throughout the book is the author’s keen interest in neurological differential diagnosis. He demonstrated how different neurological disorders often manifest in similar ways, pointing out why this mimicry greatly increases the risk of misdiagnosis. We see, for example, how a patient with chorea turns out not to have the familiar Huntington’s disease, but a much rarer and more easily missed disorder (page 32-37). Another example is the case of an exotic muscle disease which presented with symptoms the author initially misattributed to chronic fatigue syndrome (page 21). With each case study the author revealed the often subtle distinguishing features that helped to reveal the correct diagnosis. In a self-deprecating manner typical of great physicians, the author openly acknowledged his diagnostic errors, but he dwelt on the importance of learning from our slip-ups; he says ‘instead of nervously concealing them (errors), we should examine, even celebrate, our failures and mistakes‘ (page 22).
An attractive feature of the book is the abundance of references to basic science which cover subjects from anatomy to biology, from chemistry to physics. A typical example is the discussion of the ‘elemental afflictions‘, disorders resulting from the defective metabolism of sodium, lead, iron, and copper. The author showed how these biochemical derangements result in clinical syndromes such as Wilson’s and Menke’s diseases (pages 18-20). This bench-to-bedside approach was also helpful in unraveling many neurological quirks, for example why symptoms of mitochondrial disorders are most expressed in the hardest working organs…’ at rest the brain, and, on exertion our muscles’ (pages 67-72). The reference to basic science was also critical in the explaining why dysfunction in one brain network may manifest in diverse clinical syndromes; an example is how disruption of the limbic system may present as deja vu, epilepsy, Alzheimer’s disease, or Wernicke-Korsakoff syndrome (pages 135 to 137).
Another attractive quality of the book is how the author infused his portrait of the brain with striking historical references. For example, relating the history of chronic fatigue, he tracked its previous incarnations as neurasthenia in Victorian England; effort syndrome in the trenches; myalgic encephalopathy in the 1950’s; and yuppie flu in the 1980’s (page 9). His discussion of prion diseases also included an exhaustive historical chronicle of the mysterious disease, Kuru, which the Fore people of New Guinea acquired through their cannibalistic rituals (pages 42-44). Many of the historical narratives were quite revealing, for example we learn of the intense rivalry between Camillo Golgi and Santiago Ramon y Cajal, the two neuroscientists who established the structure of the neuron (pages 84-85). Other historical excursions made reference to neuroscientists such as Paul Broca, Bryan Matthews, Stanley Prusiner, and Wilder Penfield; giants of literature such as William Shakespeare, Geoffrey Chaucer, and Fyodor Dostoevsky; and paintings and sculptures by Salvadore Dali, René Magritte, Rembrandt, and Eduardo Paolozzi.
This is a grand tour de force of the brain in which the author brilliantly unified anatomy, physiology, physics, and clinical neurology. The narrative is striking for its accessibility because the author had a deft skill of explaining complex subjects in simple language. The content of the book is diverse, and the narrative is flavoured with many helpful references to the arts, literature, and history. My only criticism is his exploration of the soul which I thought was a diversion from the major theme of the book. His subjective discussion of the metaphysical I thought did little to enhance the brilliant portrait of the brain he had already brilliantly painted. These aside, this is an excellent take on a complex organ.
This is a comprehensive book on the brain which covers its diverse functions and disorders. The author communicates this in plain language. There are several learning points on clinical diagnosis and patient safety, and I highly recommend it to all doctors.
- Publisher, Place, Year: Yale University Press, New Haven, 2008
- ISBN: 978-0-300-158311
- Number of Chapters: 10
- Number of Pages: 246
- Price: £8.79
- Star Rating: 5