As I approached the task of reviewing neurology texts that could be recommended for the general internist, I found that the number of possibilities was enough to surprise even a bibliophile neurologist. To reduce this number and to add some grass roots verisimilitude, I polled our internal medicine and neurology residents and a group of community internists to find out which textbooks they used, what they liked or disliked about them, and which ones they would recommend. I have excluded some that do not have recent editions and some large works that have outlandish prices.

The residents' recommendations were interesting. Modesty led me to conclude that the many recommendations of my own textbook were based on proximity and self-preservation, and so I excluded this text from consideration. I came down to five books that could be considered; these were not a surprise. Because many internists use the neurology sections of large standard internal medicine texts, I also reviewed the latest editions of Harrison's Principles of Internal Medicine, Stein's Internal Medicine, Cecil's Essentials of Medicine, and Scientific American Medicine, edited by Rubenstein and Federman.

To gain some practical experience with these books, I read through them and then used them daily, looking up conditions and problems that I saw in my patients in each book to assess which text would provide the best information for general internists who might meet such patients in their offices.

Textbooks of Neurology

Principles of Neurology. 5th edition. RD Adams and M Victor; eds. New York: McGraw-Hill; 1993. $75.00. ISBN 0070003416. Order phone 800-262-4729.

One of the most popular texts in recent years has been the well-written Principles of Neurology. It is no coincidence that this book resembles Harrison's Principles of Internal Medicine: It was spun off from Harrison's when Adams and Victor were both editors of that book's neurology section. Principles of Neurology is a solid and substantial textbook of neurology, an excellent resource for understanding clinical neurology, and a pleasing text to use. It is nicely organized and includes good black-and-white illustrations, mostly of neuroradiology images.

Brain's Diseases of the Nervous System. 10th edition. J Walton; ed. new York: Oxford Univ Pr; 1993. $150.00. ISBN 0192619691. Order phone 800-451-7556.

Lord Brain has been succeeded as the editor of this longstanding favorite by Lord Walton, a lucid, concise, and sometimes amusing writer. The text retains the excellent writing and editing characteristic of British texts, and it served perfectly well in a North American setting.

Merritt's Textbook of Neurology. 9th edition. LP Rowland; ed. New York: Williams & Wilkins; 1994. $79.50. ISBN 0-683-07400-8. Order phone 800-527-5597.

Houston Merritt was a singularly influential teacher, and this is directly felt in his textbook. Over the years, many of Merritt's former residents have been proud to have had a hand in updating a chapter in yet another edition of this book, now ably edited by Dr. Rowland of Columbia University. This is still a leader among neurology texts, but it seems to be directed to the neurology resident rather than to a more general audience.

Neurology and General Medicine. 2nd edition. MJ Aminoff; ed. New York: Churchill Livingstone; 1994. $125.00. ISBN 0443089337. Order phone 800-553-5426.

At first sight, Aminoff's neurology and General Medicine seems ideal for general internists. In actuality, however, it is an excellent reference on internal medicine for neurology trainees rather than a good reference on neurology for internal medicine trainees (unless supplemented by another good general neurology text).

Clinical Neurology: A Modern Approach. A Hopkins. New York: Oxford Univ Pr; 1993. $39.95. ISBN 0192622625. Order phone 800-451-7556.

Clearly, most textbook authors have not read Buckminster Fuller or Marshall McLuhan for ideas on innovative books in the communication age. Most textbooks are updated versions of the textbooks of a half century ago. Anthony Hopkins, however, has advanced the traditional textbook somewhat. This British neurologist has incorporated much more clinical epidemiology and community relevance into the organization of his single-author book. The text is written in the personal, readable style that has long characterized British books and is printed in a pleasing format. Each chapter also has a well-organized bibliography, arranged according to topic subheadings, which I found particularly valuable. Persons in North America have an unfortunate myopia about journals and texts, but the epidemiology of neurologic disease in Britain is similar to that in the United States, even if practice patterns vary; this should not limit the usefulness of such a book. If you want only one neurology text, seriously consider this one, especially because it is stronger in general therapeutics than the others.

Neurology Sections in Textbooks of Internal Medicine

Harrison's Principles of Internal Medicine. 13th edition. KJ Isselbacher; ed. New York: McGraw-Hill; 1994. $98.00. ISBN 007-032-3704. Order phone 800-262-4729.

Internal medicine textbooks have a long history of providing excellent neurologic information. Osler was no mean neurologist, and his Textbook of medicine and other writings a century ago contained many important contributions and much clear thinking on neurologic conditions. When I was a medical student, there were many preferred textbooks of neurology, but most members of my class accepted the observation that the neurology section in Harrison's was as good as any current neurology textbook, and many internal medicine residents still agree. The section is small (150 pages), but it is supplemented by the excellent surrounding chapters, including the one on the approach to symptoms, one of the innovations Raymond Adams argues for after he became the neurology editor in 1954. The section on nervous system dysfunction under Cardinal Manifestations of Disease is superb and forms an important link with the later section on neurologic disorders. Harrison's improves with each edition and has a stable of outstanding neurologists under the current editor, Joe Martin. Recent editions have had a more pleasing format. The newest edition is affectionately dedicated to Adams.

Stein's Internal Medicine. 4th edition. JH Stein; ed. St. Louis: Mosby; 1994. $99.95. ISBN 0801669111. Order phone 800-426-4545.

This book also has a large neurology section, edited by J. Donald Easton. A group of recognized experts in each field has summarized the current state of clinical knowledge and provides a good reference for internists. The editing is excellent and the writing consistent.

Scientific American Medicine. E Rubenstein and DD Federman; eds. New York: Scientific American; 1978-1995, ongoing. $299.00. ISBN 0894540009. Order phone 800-545-0554.

Scientific American Medicine tries to keep up with the changing literature by providing a large, looseleaf text with monthly supplements, similar to earlier texts by Baker and Joynt. Textbooks quickly become dated, not because their information is out of date or inaccurate but because new information is lacking. For instance, much of the information in the first edition of Harrison's, published in 1950, is still correct, but the edition lacks all of the new information and therapeutic advances since that date. Scientific American Medicine is regularly updated. Each month, the publishers send out 5 to 7 new chapter updates, a revised index, a list of new references, and an excellent newsletter on new advances. A continuing medical education program on paper of disc is also available by subscription. Although expensive, I think this is a worthwhile long-term annual investment, especially on CD-ROM.

Cecil's Essentials of medicine. 3rd edition. TE Andrioli, JC Bennet, CCJ Carpenter, F Plum, and LH Smith Jr; eds. Philadelphia: WB Saunders; 1993. $41.95. ISBN W32726. Order phone 800-545-2522.

Cecil's is another traditional leader among internal medicine texts, and the neurology section, edited by Fred Plum, is well organized, well illustrated, and well referenced. It is hard to pick one over the others when deciding among Harrison's, Cecil's, or Stein's.

Discussion

Top Discussion Author & Article Info

I thought that all of the above texts were solid works and good values, but all—except for Hopkins and Scientific American Medicine—were very traditional. Their patterns and organization are just updated versions of what was published 50 years ago. Little imagination has been shown in the presentation of material, although the illustrations and the printing have improved. One interesting observation is that the rather poor photographs used to illustrate medical conditions 50 years ago have largely been replaced by excellent art, design, and graphics (the graphs and tables in Cecil's are notable examples). Another change is the move from single authors to long lists of writers, each contributing a few pages. Although it is fashionable to criticize the unevenness of multiauthor texts, unevenness did not seem to be a problem; I suspect that I has been smoothed by multiple editions over many years, overseen by a single chief editor. The switch from author to editor is noticeable in the succinct and information-laden but impersonal approach of many current books.

An internist should know the underlying principles of the nervous system (such as blood supply, cerebral organization, and localization), should know how to do a practical and efficient neurologic examination, should have a working knowledge of neurologic investigations, and should be familiar with common neurologic conditions and their treatment and management. Not all texts provide all of this, and some assume that additional information is found in other references on the internist's shelf. Most texts emphasize the background knowledge of conditions but are distressingly thin on therapeutics.

A textbook for internists may take two forms. It can be a primer that covers the neurologic history and examination, outlines how patients present and how the nervous system responds, and provides a compendium of important neurologic conditions. Alternatively, it can assume that internists have learned all of that in their training and now require a reference work on neurologic conditions. Most textbooks are reference works produced with the assumption that the general primers covering examination and approaches are in that basket of books aimed at medical students. I think it is an error to assume that the important basic knowledge of neurologic assessment is present: Many internal medicine residents do not have much neurologic experience during their training because of the pressure to learn so much about so many other fields. Also, my experience with general physicians has suggested that the major deficiency is not in neurologic knowledge but in a negative attitude about neurology patients and a lack of confidence in doing a reasonable, efficient neurologic examination.

Disclaimers may be necessary in today's litigious atmosphere, but they are sometimes amusing. Adams and Victor, for instance, take no responsibility for the accuracy and completeness of the information in their text, for errors or omissions, or for the results obtained by using their information. They encourage readers to confirm the information in other sources, which seems impractical if an internist needs a ready source of information with which to manage patients.

Each text has a serviceable index, but Harrison's has the best. In fact, many physicians have used the index in Harrison's as the basis for their personal medical filing systems. References are reasonable in each text, but some are quite dated. The most helpful arrangement of references is in Hopkins, where the various topics in each chapter have subsections in the reference list. Although Hopkins has concentrated on general and review articles, some of these are 10 or more years old.

Although I found each book to be a major and impressive work and a reliable resource for the internist, I found three common failings and surprised myself by reaching a negative conclusion on the textbook as a resource for today's internist.

The most common failing was that authors were so concise in the interest of space that the flavor and color—and, in the end, the feeling and understanding—of each neurologic condition was limited. The textbook description of a condition necessarily differs from the experience of a real patient, but it doesn't have to differ so much. Authors should struggle to provide a window into the patient's experience of a disease rather than just a biological outline. This is not a new problem caused by expanding information. Rather, it has been characteristic of textbooks through the century and is a feature of this kind of writing, particularly when done by multiple authors.

Another common failing was a tendency to explain and describe a neurologic condition well but to give cursory attention to management and treatment; this is, perhaps, a longstanding failing of many neurologists. Finally, common conditions were underemphasized in relation to their importance in practice. For instance, Stein's includes 10 well-written pages on abnormalities of the oculomotor system but only 2 pages on migraine. Hopkins, who has done a lot of work on the frequency of neurologic conditions and patterns of office and ambulatory neurology, uses the epidemiologic approach to organize his text; thus, his book is more balanced and more relevant to practice.

What of the repeated predictions of the demise of textbooks? Reviewing these books was interesting, reassuring, disappointing, and depressing. It was interesting because all are surprisingly well written. It was reassuring because they are all well-compiled, comprehensive, and generally useful resources—each would serve well as your primary textbook on neurology. It was disappointing because I continually teach that neurology has moved fro a descriptive to a therapeutic discipline, and most of these texts are dismal in their practical recommendations for managing patients. And it was depressing because, as a textbook author, I became convinced that the textbook is not a good way to obtain understanding or information in this day and age.

After spending many months perusing dozens of books for this review, and contemplating a fifth edition of my own, I must conclude that although its death is not imminent, the textbook is looking unwell. This is the information age. An information method scheduled for oblivion is one that relies on an expensive written text that is too succinct and cursory and that is a year and a half old when purchased. The age of computer-assisted access to rapid, accurate information in on-line electronic databases, journals, and texts is just a matter of time.

I was impressed by the limitations of these textbooks and by the fact that they were beginning to look like relics from the past. I have always felt that textbooks would continue for the reason that books in general continue: They are inexpensive, you can caress them, you can slip them in your pocket, you can read them on a plane or at the beach, and you can enjoy their appearance on a shelf. I think that books will last, but in an age when data are complex and rapidly changing, we must have information sources better than textbooks for medical knowledge and patient management. The predictions of the death of the textbook were not inaccurate, just premature.