Book Review

Greenfield's Neuropathology

N Engl J Med 1993; 328:1719June 10, 1993

Article

Greenfield's Neuropathology
Fifth edition. Edited by J. Hume Adams and Leo W. Duchen. 1557 pp., illustrated. New York, Oxford University Press, 1992. $195. ISBN: 0-19-520948-6

Asking a neuropathologist to review Greenfield's Neuropathology is like asking an art critic to review the Statue of Liberty. Like the Statue of Liberty, Greenfield has a monumental quality. But if the Statue of Liberty came out in a fifth edition that was half again as large as the fourth, someone would have to take notice of it.

As in previous editions, Greenfield covers all of neuropathology except tumors. Tumors are covered in the “companion volume,” Russell and Rubenstein's Pathology of Tumors of the Nervous System, also in its fifth edition (Baltimore: Williams and Wilkins, 1989). The authors of Greenfield are all from the United Kingdom except for one (Rorke, from Philadelphia), who contributes an excellent chapter on perinatal brain damage. Diseases of the central nervous system are discussed in 14 chapters organized according to pathogenesis. There are additional chapters on diseases of the basal ganglia, cerebellum, and motor neurons; the hypothalamus and pituitary gland; the spine and spinal cord; epilepsy; and aging and the dementias. There is also a chapter on diseases of the peripheral nerves, and another on skeletal muscle.

The clarity of writing for which British and Irish writers are known is not evident in this book. This is heavy reading, even for someone in the field. Writing about neuropathology does not need to be tedious. Surgical Pathology of the Nervous System and Its Coverings, by Burger et al. (3rd ed. New York: Churchill Livingstone, 1991), continues to be delightful to read even though the diseases that it discusses are depressing. The writing in Greenfield is serviceable but dull.

The strength of the book is its detailed description of the pathological anatomy of neurologic diseases. Almost every chapter covers these aspects of neuropathology better than any other book I know. The illustrations are extensive and of very high quality. I kept the review copy on my desk for several months and made a point of looking up an answer to every question about pathological anatomy that trainees and colleagues asked me. I was almost always able to find an answer in considerable detail.

Neuropathology is more than pathological anatomy, however, and here Greenfield is spottier in its coverage. There is great variation from chapter to chapter in the degree to which molecular biology and other modern fields are represented. For example, the chapter on hypoxia and vascular disorders contains a good deal of information on the role of excitotoxins in the pathogenesis of hypoxic brain damage, but there is no discussion of the importance of these substances in the discussion of Huntington's disease. In fact, the chapter on disease of the basal ganglia, cerebellum, and motor neurons gives little or no information on modern theories of the pathogenesis of the disorders that it covers -- among them, Parkinson's disease, Huntington's disease, the spinocerebellar degenerations, and amyotrophic lateral sclerosis. Although the causes of none of these diseases are known, there is much active research into almost all of them, little of which is reflected in the chapter. Too often, the discussion is limited to gross alterations and histopathology, and even in these areas there is little discussion of the contribution of such techniques as in situ hybridization and the polymerase chain reaction to our understanding of neuropathology.

Andre Gide, when asked who was France's greatest poet of the 19th century, replied, “Hugo -- alas.” Greenfield used to be the only complete textbook of neuropathology. It now has competition from Robertson and Davis' Textbook of Neuropathology (2nd ed. Baltimore: Williams and Wilkins, 1991) and Weller's Nervous System, Muscle and Eyes (vol. 4 in Symmers' Systemic Pathology. New York: Churchill Livingstone, 1990). Either of these is easier to read than Greenfield and would serve the trainee in neuropathology better. No practicing neuropathologist can be without Greenfield, but the best neuropathology book remains “Greenfield -- alas.”

Lester S. Adelman, M.D.
New England Medical Center, Boston, MA 02111