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Neurology is the broad field of clinical study of the nervous system. As a profession, it is a highly enjoyable endeavor that is a constant source of professional and personal enrichment. Through Principles of Neurology we have the privilege of continuing a tradition established 35 years ago by our esteemed teachers Dr. Raymond D. Adams and Dr. Maurice Victor. Our friend and colleague, Dr. Robert Brown, ably participated in the eighth edition, adding his expertise in the neurosciences, much to our benefit and that of the book.

Principles of Neurology originated from the chapters on neurological diseases in the first several editions of Harrison's Principles of Internal Medicine. The continued expansion of these sections by Adams and Victor, despite repeated commitments to shortening them, led an exasperated Tinsley Harrison to exclaim to Dr. Adams “....we'll have to change the name of the book to Principles of Internal Medicine and Details of Neurology.” Ray Adams wrote the entire first edition of the book in longhand during his summer vacation of 1975 in Lausanne and asked his highly regarded young colleague Maurice Victor to round out the manuscript over the following year. Adams and Victor attracted considerable attention by initiating a new style of pedagogy that emphasized the basic principles of neurology before introducing the disease entities.

While the enormous advances in imaging, genetics, molecular biology, and pharmacology have improved our capacity to diagnose and treat disorders of the nervous system, they have not reduced the necessity to understand certain basic principles of anatomy and physiology, to obtain the correct history, perform a capable neurological examination and to cohere them based on a body of clinical knowledge and experience. We continue the original structure of the book, re-affirming that comprehensive knowledge of clinical neurology is required to meet the challenge of this sophisticated specialty. We have also maintained personal authorship with the hope that a single voice will allow the reader to enjoy the experience of learning the field from two longtime practitioners in a manner similar to the way we learned it from the original authors and their colleagues.

In taking the responsibility of revising this book, we acknowledge that pedagogy in medicine has changed enormously to accommodate technical advances, particularly those in imaging. However, certain principles seem immutable and they derive from the traditional principles, virtues, and logic of medicine that dominate neurological thinking. Clinical neurology, being an applied science, depends on a set of heuristics that direct the clinician to the best diagnosis and therapeutic plan. This book provides an exposition of clinical material in an order that should allow the reader to obtain a comprehensive view of the field and at the same time appreciate the full breadth and depth of each disease of the nervous tissue. At the same time we have written the chapters on major diseases in a manner that allows the book to be used as a reference in depth.

Certainly, advances in neuroscience inform one's perspective on the nature of disease and produce a fuller appreciation of the manifestations in each patient. A case in point is the large number of previously inexplicable degenerative diseases that have yielded to scientific understanding on the levels of pathology, genetics, subcellular mechanisms, and neurochemistry. At the same time, therapeutic advances often precede basic understanding of disease and the neurologist has the duty to provide the best possible treatment at the time, even if science has not provided a full explanation or mechanism. Examples abound; we have an incomplete understanding of epilepsy, Parkinson disease and multiple sclerosis but many reasonably effective treatments have been devised. While the neurosciences are the instruments of advance in understanding disease, the work of clinical neurology is more pragmatic, yet it retains its own form of scholarship. Neurology is not simply a trade in relation to the sciences. Difficulty in mastering neurology derives from a need to combine considerable knowledge and personal experience with special skills of observation and disciplined thinking. Our goal is to present an assemblage of clinical knowledge, and we hope wisdom, rather than disembodied facts. The book contains information that should be the property of the well-educated physician at all levels, including the medical student, resident, practitioner and academic physician. The neurologist stands at the nexus of the study of the nervous system and includes many aspects of general medicine, psychiatry, neurosurgery, pain management, rehabilitation, ophthalmology, otolaryngology, anesthesiology, critical care and emergency medicine and Neurology serves as Medicine's spokesperson to society on matters such as mental capability, learning and teaching, aging and the brain, death, and disability. Therefore the breadth of Neurology has directed the liberal inclusion of material in the book.

Neurology, like internal medicine, has become increasingly subspecialized. Modern departments of neurology include divisions of stroke, epilepsy, movement disorders, sleep, neuromuscular disease, multiple sclerosis, pain and headache, otoneurology, neuro-ophthalmology, cognitive and behavioral neurology, critical care neurology, spinal disorders, neuro-infectious diseases, cancer neurology, and pediatric neurology. Yet, there is a need for all clinicians, including the subspecialist, to maintain a comprehensive understanding of the major categories of neurological diseases. We respect and commend the community practitioner who by necessity maintains a broad gauge view of the field and we write with them in mind.

We thank our many colleagues who reviewed chapters and suggested alterations or additions. Several readers made invaluable contributions: Roland Eastman, Anthony Amato, Edward Bromfield, James Lance, Marc Dinkin, Jun Kimura, Jaime Toro, Elio Lugaresi, and Werner Hacke. We are indebted to Susan Pioli for her superb editorial skills, Desi Allevato of Silverchair for her compositing efforts, and Kim Davis of McGraw-Hill for her efficient work as our developmental editor. We thank Anne Sydor of McGraw-Hill for her publishing expertise and for promoting the goals of the book.

This ninth edition introduces as an author a consummate neurologic clinician and teacher, Dr. Martin A. Samuels. Marty brings intelligence, style and accessibility to Neurology and particularly to its interface with Internal Medicine. His thoughtfulness and clinical experience extends to all aspects of clinical material, and his exceptional teaching skills have been used to full extent in updating the text. It has been a pleasure for us to challenge each other in considering the needs of our clinician colleagues during the process of rewriting the text.

We are, of course, products of our exposure to influential if not charismatic teachers. Raymond D. Adams was the progenitor of several generations of influential neurologists. He inculcated a method for approaching complicated neurological problems in a manageable way. Observing his analysis of a patient's problem gave students the impression of remarkable ease and fluidity reminiscent of watching a gifted artist or musician. Dr. Adams knew the field so well and thought so critically, based in large part on his experience with neuropathology, that he allowed all of his residents to believe that they too, could and should aspire to excellence. His encouragement and cultivation of enormously talented colleagues such as C. Miller Fisher and E.P. Richardson, among many others of that time, reflected an unpretentious self-confidence, flexibility of mind, and mastery that derived enjoyment from the brightness around him. He read widely in neurology, medicine, and literature (in several languages; he often reminded us by providing articles that were beyond our personal reach) and was always ready to incorporate the modern advances in science into his thinking. His hundreds of residents wished to model themselves after him not because of personal suasion or celebrity but because of a genuine admiration for his intellect and intensely cultivated clinical skills. In tribute to Dr. Adams this ninth edition, published soon after his death, serves as recognition of his lasting accomplishments from his grateful students.

Allan H. Ropper, MD
Martin A. Samuels, MD
Boston, March 2009

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