Preface

We are very pleased to bring you the twelfth edition of Adams and Victor’s Principles of Neurology. The originators of this book, Raymond D. Adams and Maurice Victor, insisted that the basis of the practice of neurology as a medical discipline must always be related back to the patient. This guides the format and approach that we continue to adhere in the current edition. In the past few decades, there has been an explosion in understanding of the fundamental causes of neurological diseases. Just a few examples are the reclassification of brain tumors based on genetic changes and the novel autoantibody disorders that proliferate with each edition of major medical journals. In the present edition, there is hardly a category of disease that has not begun to yield to the tools of molecular biology and genetics

The well-educated neurologist must be familiar with these advances and develop a foundation upon which to absorb ongoing discoveries, particularly as they pertain to modern treatment. But these do not always provide the basis for excellence in clinical practice. There is not so much a gap between science and practice as there is a tenuous equilibrium. Finding the sweet spot between them is a goal of the book. This project begins with a firm grounding in the principles of anatomy, physiology, biochemistry, and genetics that are essential to understanding neurological symptoms and signs that are artfully extracted, processed, and abstracted by the clinician in proximity to the patient. The first parts of the book attach these principles to clinical symptoms and signs. In subsequent parts, diseases are grouped by their clinical manifestations: dementia, ataxia, visual loss, muscular weakness, headache, depression, convulsion, and so on. This is after all, how patients present to physicians, as patients are not in a position to express the fundamental underlying biological cause of their aliments. The final sections tackle the diseases themselves, decidedly from the perspective of how each affects the nervous system rather than as isolated entities. This affords the reader an opportunity to comprehend what can, and as importantly what cannot, happen to the nervous system, a powerful tool that sharpens diagnostic skills and avoids overly broad differential diagnoses.

More than laboratory science, clinical trials have continued to build the background of information that applies to large groups of patients with neurological disease, namely clinical trials that now guide practice. Clinicians are aware, however, that the results of a trial have less certain meaning for an individual patient. Our teacher C.M. Fisher was fond of the quip “There ain’t no more than one average Englishman.” Knowledge of trial design and statistical methods is helpful in gauging the certainty with which to apply information from trials and we try to point out the strengths and weaknesses of the results from major trials to provide a context for implementing their results. It is the skillful use of this information that this book aims to inform. Will the single patient be helped or harmed? Because medicine deals with the realities and complexities of illness in the individual, the clinician makes a best approximation of the correct course. The wise application of science, evidence from trials, closely coupled to the traditional value of the neurological history and examination—essentially the craft of neurology—are the main purpose of this edition of Principles of Neurology.

Furthermore, there is a vast territory that can only be explored in the human representations of disease. Aphasia, confusional states, headache, amnesia, developmental delay, in fact most of human behavior, have no animal models or only crude approximations. Examples of what makes us who we are fall in the purview of neurologists every day by demonstrating what is lost when the nervous system is damaged. Neurologists are inevitably clinical investigators and they depend on astute observation in the clinic and at the bedside. They have something to say on development, education, aging, the boundaries of what is normal and abnormal, and many other appended issues, if they choose to look at these subjects through the lens of daily practice. We also believe that teaching the skills of neurological observation is a trust that must not be broken and hope that a firm grounding in the way diseases affect patients will assist students, residents and early career neurologists in internalizing their experiences of each patient and the subsequent transgenerational transmission of knowledge about diseases of the nervous system.

As has been our tradition, the book is written in a conversational style and we do not eschew stating our personal preferences when they are based on experience. We continue to find that readers value the uniformity of voice and approach of a few individual authors, rather than a discursive list of topics and writers. We thank Dr. Tim Lachman and the many others who read portions of this and previous editions for invaluable assistance in pointing out errors and the readers who have written to us with corrections and suggestions for improving the book.

We hope this edition allows the physician to use the material as a basis for continued professional growth and enjoyment at all stages of professional life that will profit general and specialist clinicians. Welcome again to our world in this twelfth edition of Adams and Victor’s Principles of Neurology on its 50th anniversary.