Marshall, Randolph S. MD
Anyone who has heard Professor Kenneth Heilman, MD, speak cannot help but be affected by his boyish enthusiasm for his subject matter. His lectures are often unadorned by tables, figures, or even slides, yet they are animated, intimate, Socratic, and infectious. It is in this spirit of immediacy and personal wonder that Dr. Heilman's new book, Matter of Mind: A neurologist's view of brain-behavior relationships, is best read.
MODERN HISTORY: BEHAVIORAL NEUROLOGY
Dr. Heilman's book is an adventurous romp through the modern history of behavioral neurology, viewed through the eyes of a protagonist who contributed substantially to its shaping. The book's scope includes the adventures of the young Professor Heilman launching his pursuit of behavioral neurology in the mid-1950s as an eager but confident medical student at the University of Virginia, when his interest was piqued by a patient with an unusual right hemisphere syndrome.
We witness his early explorations of disorders of language, attention, memory, emotions, and self-awareness during his fellowship with Derek E. Denny-Brown and Norman Geschwind at the Harvard Neurological Unit of Boston City Hospital. We follow the formation of some of the tenets of current neurobehavioral theory, and come to understand Dr. Heilman's legacy, passed on to the many residents and fellows he has trained – some of whom now rank among the most important figures in behavioral neurology.
Matter of Mind is structured as a survey of the main topics of behavioral neurology. After a brief, somewhat sketchy introduction that touches on historical theories of brain-behavior relationships from Aristotle to Descartes to Broca, and Wernicke to Geschwind, Dr. Heilman presents the major neurobehavioral syndromes – aphasia, emotional dysfunction, inattention, disorders of self-awareness, memory loss, cognitive motor dysfunction, sensory misperception, and disorders of intention and action – in brief, readable chapters.
The topics are treated in varying depths, however. The chapter on language is appropriately the longest, but even at 41 pages one feels somewhat short-changed as a practicing neurologist. Dr. Heilman's treatment of conduction aphasia, for example, is extremely brief, and he presents, unmodified, a single diagram and a single theory expounded nearly 40 years ago by his mentor, Dr. Geschwind.
For a more comprehensive and rigorous review of neurobehavior, the interested neurologist might turn to Dr. Heilman's Clinical Neuropsychology, which he edited through three editions with his colleague, Professor Edward Valenstein. That review of neurobehavior was published in 1993, but contains well-referenced, extensive discussions of many of the topics that are covered in Dr. Heilman's new book, written by many of the leaders in the field. For those fascinated by neurobehavioral syndromes and how the disordered mind can be understood from intensive observation and experimental deduction, however, Matter of Mind offers an important perspective.
VIVACIOUS NARRATIVE STYLE
Dr. Heilman's vivacious narrative style permeates the anecdotes. We get to know the man with apraxia who used his finger and toothbrush like chopsticks to eat corn, and the wealthiest woman in Florida whose visual agnosia prevented her from recognizing money. Parsing out the individual abilities and dysfunctions of these patients stirs the reader's curiosity that such behavioral dissociations can occur.
The narrative is most compelling when the extensive clinical descriptions are accompanied by exposition of the interactive process involved in investigation of the behavior. In examining a 72-year-old man with a transcortical sensory aphasia, for example, we observe Dr. Heilman and his colleagues as they develop a semantic picture-matching test that penetrates the patient's inability to understand the semantic connection between a spoken name, a written name, and a picture of an object.
One feels the elation of the investigators as the semantic connection between a picture of a football and a goal post finally induces the patient to grin, sweep his hand down in the Florida State University football “chop,” then perform correctly on nearly all the subsequent picture-matching trials that he had failed up to that point.
ORIGINS OF MAJOR SYNDROMES
The origins of the study of many important syndromes are described in the book. Treating a patient whose distraught husband was ready to leave her because she was unable to recognize his emotions, for example, Dr. Heilman launches a new investigation of the anatomical basis of dysprosody, the inability to identify the emotional tone of speech. Other neurobehavioral syndromes, such as “motor neglect,” ideomotor dyspraxia, and somatosensory extinction are treated similarly, emerging from bedside observation and evolving under Dr. Heilman's investigation to the textbook conceptions of the syndromes as medical students learn them today.
In a section on“pure word deafness,” Dr. Heilman provides extensive (and welcome) clinical detail on a single patient who had been deemed a“faker” by the attending neurologist until Dr. Geschwind swept in to diagnose another type of “disconnection” syndrome. Even with these more extensive discussions, however, the book is more informative at the level of clinical detail than as a serious examination of the individual topics.
Many texts, including some that Dr. Heilman cites, are devoted to topics that are considered only briefly here. Some of his explanations are interesting and plausible through introspection, but are not offered with possible alternatives, or tested experimentally. Anton syndrome (unawareness of blindness), for example, is described as visual imagery taking over when vision is lost. He makes the analogy to a TV cutting off when the VCR starts. This makes sense conceptually, but how this could arise is not discussed.
In another example, Dr. Heilman saw a patient with phantom limb pain during his internship. An expert gave the patient “exercises” for the lost limb to reduce the pain. That is a fascinating concept, one that could contribute experimentally to understanding the phantom limb phenomenon and to its negative counterpart, asomatognosia, the loss of ability to perceive one's body or parts, but we never find out if the experiment works.
TARGETED FOR LAY AUDIENCE
Figure. Matter of Mi...Image Tools
Although there is much for the practicing neurologist to glean from the detailed descriptions of patient encounters, the book seems to be targeted predominantly toward a lay audience. Physiological information is presented at a rudimentary level, for example: “One nerve activates another by emitting a chemical called a neurotransmitter.”
In addition, everyone we meet in the book, whether an internationally recognized figure in neurology or a first year resident who has asked an insightful question, is presented informally, by first and last name, even by nickname, and without title. While this stylistic choice is consistent with Professor Heilman's Socratic approach to teaching, and perhaps to a life view in which everyone should be treated equally, it leaves a lay audience uninformed about the stature of these colleagues.
Many of the discussions are classic elements of behavioral neurology. Most were created before modern imaging was available, and consequently, as strong as the theories are conceptually, many have been refuted. The references in some chapters are 20 to 30 years old. Although many theories from that era are still valid, the absence of more recent references can make the text dated.
SINGLE CASE REVIEWS
In addition, many of the discussions are presented on the basis of a single, unique case. The more unique the case, the more difficult it is to find general principles. The rich woman with visual agnosia for money turns out to have Alzheimer disease. From this unusual case, Dr. Heilman presents a lengthy discussion of different types of visual agnosia, offering a diagram of anatomical structures and interconnected conceptual fields that might explain the clinical findings. But because Alzheimer disease is a generalized, degenerative disease and only rarely produces the type of visual agnosia described, it may not be generalizable in the“lesion method” used by Dr. Heilman.
Conceptualizing the mind as Dr. Heilman does is a descriptive process. Models built on observations of individuals can help explain the observations. Subsequent observations in similar cases can support or modify of the model, but the accumulated body of information – which in the case of Dr. Heilman is voluminous – is in the end an iterative process, building on its own theories.
Dr. Heilman states in the introduction that neuropsychological research has focused on detailing the anatomical and conceptual framework of complex behaviors, but there is still little information about the connections between behavioral modules. Perhaps that is why Dr. Heilman offers no concluding summary and makes no attempt to frame a larger understanding of brain-behavior relationships from the individual models.
The dearth of larger principles leaves one wanting more at the end of the book. This does not negate this laudable and monumental effort. For any reader, Matter of Mind fosters an appreciation for the intricacies and subtlety of brain-behavior relationships. The information is presented in a way a layperson can understand, and a neurologist, young or mature, can relish.
CATEGORY FOR BOOK?
Where on the bookshelf does Matter of Mind belong? It can be a welcome addition to the collection of the general neurologist who thrives on patient narrative and interesting case descriptions, as long as no offense is taken by the rudimentary pitch of the medical information. Non-neurologists and lay readers may appreciate the book for the curiosity of unusual clinical syndromes.
I have placed my copy between the Oliver Sacks book, The Man Who Mistook His Wife for a Hat, and MacDonald Critchley's The Parietal Lobes. Within easy reach, I can pull it off the shelf when a medical student, interest piqued by a patient with an unusual right hemisphere syndrome, wants to learn more.