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前 言

As the rest of medicine changes, so does neurology.

Neurologic diagnosis and treatment has been so vastly altered by modern neuroimaging, molecular biology, and genetics that the original authors of this book, Raymond D Adams and Maurice Victor, would barely recognize the practices of today. Secular interest in neurologic diseases is also expanding because of the large num- ber of problems of the brain, spinal cord, nerves, and muscles that arise with aging and from the treatment and control of other, non-neurologic, diseases. Whereas cancer and heart disease had occupied foremost posi- tions in the minds of individuals within developed societies, Alzheimer, Parkinson, and related diseases are central to the modern conversation about the quality of life. Moreover, the desire to understand the workings of the brain and to gain insights into human behavior has become a preoccupation of the public. At the same time, the manner in which information, both accurate and otherwise, is transmitted about the nervous system and neurologic diseases has changed. Access to informa- tion about diseases, accepted treatments, and clinical symptoms and signs, ubiquitously clutters the internet. Physicians now less frequently seek a comprehensive understanding of a disease or class of diseases, the whole story if you will, but instead favor rapid access to single answers to a clinical problem.

For many reasons, particularly the last of these regarding the nature of medical information, writing a textbook on neurology has become a complex enterprise. We have even asked ourselves if there is a role for a text- book in the modern era, especially one written by only three authors. Yet, in identifying the characteristics of the capable clinician, one who is equipped to help patients and play a role in society to the fullest extent possible, we continuously return to the need for careful clinical analysis that is combined with a deep knowledge of disease. these are still the basis for high-quality practice and teaching. even if the current goals of efficiency and economy in medicine are to be met, neurology is so com- plex that the confident implementation of a plan of diag- nostic or therapeutic action quickly finds itself beyond algorithms, flow charts, and guidelines. the goal of our textbook therefore is to provide neurologic knowledge in an assembled way that transcends facts and information and to present this knowledge in a context that cannot be attained by disembodied details. While the biological bases of neurologic diseases are being discovered rapidly, the major contribution of the clinical neurologist remains, as it is for the whole of medicine: a synthesis of knowing how to listen to the patient, where to find the salient neurologic signs, and what to acquire from labora- tory tests and imaging.

There is always a risk of such a book being simply archival. But the dynamic nature of modern neurologyrequires more than ever a type of integration amongknowledge of clinical neurosciences, traditional neurol- ogy, and the expanding scientific literature on disease mechanisms. only a text that has been thoughtfully constructed for the educated neurologist can fulfill this need and we hope that we have done so in this edition. Furthermore, in appropriate conformity to the methods by which physicians obtain information, McGraw-Hill has made an investment in their Access Medicine web- site that will highlight our book as well as several other neurology texts. combined with these books will be sophisticated search functions, teaching curricula for stu- dents and residents, and, hopefully in the future, a form of interaction with us, the authors. Another inception has been the addition of color figures and photographs to this edition in order to make the visual material more acces- sible and appropriate for the web version.

To these ends, we offer the current 10th edition of Principles of Neurology to meet the needs of the seasoned as well as the aspiring neurologist, neurosurgeon, inter- nist, psychiatrist, pediatrician, emergency physician, physiatrist, and all clinicians who have need of a com- prehensive discussion on neurologic problems. We begin with an explanation of the functioning of the nervous system as it pertains to neurologic disease in the first part of the book, followed by detailed descriptions of the clinical aspects of neurology in its great diversity. in all matters, we have put the patient and relief of suffer- ing from neurologic disease in a central place. the book is meant to be practical without being prescriptive and readable without being too exhaustive. When there is a digression, it has been purposely structured to complete a picture of a particular disease. We have also retained historical aspects of many diseases that are central to the understanding of the specialty and its place in medicine.

By taking an inclusive and yet sensibly chosen clini- cal approach, we do not eschew or criticize the modern movement to homogenize medicine in order to attain uniformity of practice. We ourselves have witnessed over 35 years the unappealing aspects of idiosyncratic practices, which were based on limited basic informa- tion and on a superficial understanding of neurology. Nonetheless, the complexity of neurologic diseases, espe- cially now, puts the practitioner in a position of choosing among many options for diagnosis and treatment that are equivalent, or for which the results are uncertain. clinical trials abound in neurology and set a direction for clinical practice in large populations, but are difficult to apply to individual patients. the need for a coherent method of clinical work is one reason we have retained author- ship rather than editorial management that character- izes many textbooks in other areas of medicine. Limited authorship permits a uniform style of writing and level of exposition across subject matter and chapter headings.

It also allows us to judiciously include our own experiences and opinions when we feel there is something more to say than is evident in published articles. our comments should be taken as advisory and we have no doubt that our colleagues in practice will develop their own views based on the body of information provided in the book and what is available from many outside sources. to the extent that some of the views we express in the book may be perceived as having a Boston-centric outlook, we appeal to the readers forbearance. We have neither a proprietary formula for success in neurology nor the answers to many of the big clinical questions. if there is a stylistic aspect that comes through in the book, we hope it is still that neurology must be taken one patient at a time.

We gratefully acknowledge on the following pages several experts in particular fields of neurology whose help was invaluable in revising this edition. We sought their guidance because of the high regard we have fortheir clinical skills and experience. if there are concernsregarding specific comments in the book, they are our responsibility.

With this edition, we introduce our colleague JoshuaP. Klein, MD, PhD, the chief of the Division of Hospital Neurology in the Department of Neurology at Brigham and Womens Hospital. Dr. Klein is dually trained in neurology and neuroradiology. He brings a wealth of perspective on imaging and has been a powerful partner in moving the book toward a more modern idiom that recognizes the centrality of neuroimaging in practice. it is a privilege to have him join us to bring the book through the beginning of the current century.

Allan H. Ropper, MD

Martin A. Samuels, MD Joshua P. Klein, MD, PhD