Neurology. Charles H. ClarkeЧитать онлайн книгу.

Such beliefs are not restricted to poor societies. In Europe, with epilepsy, over 50% feel stigmatised. In the United States in some states until the 1950s, people with epilepsy were prohibited from marrying and could be sterilised; until the 1970s they could be excluded from restaurants and theatres.

Headache is another: people with headaches feel stigmatised at work. There is the well‐known male attitude to women with headaches and menstrual discomfort.

Doctors and health professional should be aware, not only of such prejudices, but also of their own attitudes.

Costs and Impact

Ill health imposes high costs, both on the patient and family everywhere. However, in poorer countries the proportion of family income spent on health is particularly high, not least as ill health results in unemployment.

In the United Kingdom, any chronic illness (over one year) is likely to diminish the income of a family by >50%.

Even in countries where health services are free at the point of delivery, the cost of all illness is substantial.

Neurological illnesses because of their chronic nature are particularly onerous. The impact of a disease depends upon personal wealth, the healthcare system and social networks available.

Treatment Gaps

Taking epilepsy again, a Treatment Gap is the percentage with seizures who do not receive anti‐epileptic drugs (AEDs). In Pakistan, the Philippines and Ecuador there are epilepsy TGs of 80–95%, in India around 75%, but <5% in the United Kingdom, pre‐COVID. Reasons include lack of health care, cost, drug availability, cultural factors, and stigma – and failure to grasp that AEDS are effective. Campaigns to narrow TGs are priorities.

Improvements

Improvements in health delivery rest largely with governments, their knowledge and resources. Non‐provision is largely due to policies. Success or failure to deliver provides stark contrasts, often unrelated to GDP. Most European countries have integrated care systems, that aim to improve the health of the populace. So does Cuba, despite its poverty. In the US, despite some of the world’s finest medical institutions such a system remains in its infancy. Quite where we are heading in the United Kingdom and in Europe, from 2021, is known to no one.

Acknowledgements

I am indebted to Professor Simon Shorvon who wrote the original chapter in Neurology A Queen Square Textbook Second Edition. Edited by Charles Clarke, Robin Howard, Martin Rossor & Simon Shorvon, Wiley Blackwell, 2016.

I am also most grateful to Dame Sally Davies, former Chief Medical of Health for England and to Dr Elizabeth Davies, Reader in Cancer & Public Health, King’s College, London who reviewed and commented on my text.

References

1 Olesen J, Leonardi M. The burden of brain disease in Europe. Eur J Neurol 2003; 10: 471–477.

2 Wallace H, Shorvon SD, Tallis R. Age‐specific incidence and prevalence rates of treated epilepsy in an unselected population of 2,052,922 and age‐specific fertility rates of women with epilepsy. Lancet 1998; 26: 1970–1973.

2 Movement, Sensation and The Silent Brain

Anatomical complexities of the nervous system became apparent in the late nineteenth century. Highlights were the pathways described by Santiago Ramón y Cajal in the 1890s and later the cortical mapping by Brodmann and the work of Alf Brodal. However, remarkably little neuroanatomy was required to practice sensibly and safely. To an extent this remains so. The neuroanatomy here is in excess of the needs of most general neurologists but further study is essential in many aspects of neuroscience.

First, here is an overview of the motor and sensory pathways of the brain and cord – the basic wiring that must be understood. I deal with this largely as illustrations. I also summarise what I call the Silent Brain, vital but less obvious – regions such as the thalamus. Cortical function is dealt with in Chapter 5. For neurones, nerves, glia and myelin see Chapter 10. Chapter 13 deals with the cranial nerves. Neuro‐ophthalmology is in Chapter 14, Neuro‐Otology in Chapter 15 and the autonomic nervous system in Chapter 24.

The overall anatomy of the brain is illustrated in Figure 2.1

ABC of Movement: Cortical, Extrapyramidal and Cerebellar Function

Movement – skilled, coordinated and fast – is highly developed in mammals. Rudimentary objectives are feeding, survival and reproduction and in Mankind, skilled use of tools, weapons and instruments of creative art.

1 Corticospinal (pyramidal) tracts originate in the motor cortex, somatosensory and limbic areas to reach cranial nerve nuclei and cord anterior horn cells. Dysfunction produces loss of skilled movement, weakness, spasticity and reflex change. Pyramidal describes the triangular cross‐section of the tract in the medulla. Pyramidal is used here interchangeably with corticospinal.

2 The striatal (a.k.a. extrapyramidal) system facilitates fast, fluid movement. Hallmarks of dysfunction are slowness (bradykinesia), stiffness (rigidity), rest tremor, all seen typically in Parkinson’s and some movement disorders. Broadly, these are basal ganglia functions.

3 The cerebellum coordinates smooth movement, and balance. Ataxia and action tremor are features of dysfunction.

Schematic illustration of brain: overall anatomy (a) Lateral view (b) Midsagittal section (c) Ventral view.

Figure 2.1 Brain: overall anatomy (a) Lateral view (b) Midsagittal section (c) Ventral view.

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