Vertigo: Its Multisensory Syndromes (2nd edn), by Thomas Brandt

Springer, 1999. £140.00, $249.00, DM 398 (xvii+503 pages)ISBN 3540199349Thomas Brandt has completely updated and rewritten his personal and unique approach to the clinical problem of vertigo, which was originally published in 1991. The revision is spectacular. I confess, I am addicted to Brandt’s approach and will be largely effusive in my praise of this book. It will have strong appeal to those physicians who must diagnose and treat such patients, and to scientists who are investigating how humans maintain their sense of equilibrium and spatial orientation. But what makes this book different from what is extant? Brandt eschews the traditional approach to the vestibular system: first the strict anatomy and physiology, and then the clinical implications. Instead he dives directly into the specific clinical problems and then provides the necessary correlations, that is, the relevant physiology and anatomy. And there is usually an appropriate scheme that allows one to put the clinical problem into a pathophysiological framework. Even in the introductory chapters, one is never far away from the clinical problems. This approach will be especially welcomed by the ‘dizzy doctors’ who have long struggled with these difficult clinical problems.Brandt’s compass is much more than the traditional focus on vertigo and nystagmus; he also emphasizes posture, gait, and, in particular, perception and misperception. This broad clinical approach is timely as neuroscience expands its idea of the vestibular system to include the more-inclusive concept of spatial orientation. Scientists now investigate how the neural networks in the cerebral hemispheres combine information from our labyrinths with that provided by our other senses and that derived from our internal expectations. PET and fMRI are allowing us to explore how this is all accomplished in normal humans and soon, in patients.A few features of the book should be particularly mentioned. The illustrations, especially the MRI scans, are outstanding. The text, which is concise, is richly supplemented with useful tables and diagrams. Each chapter has a relatively detailed introductory page that directs the reader’s attention. The book is well referenced with a good mixture of the classical and the latest citations. Perhaps one could quibble with the glossary with which Brandt begins the book. Does a ‘rotational vertebral artery occlusion’ imply that the artery is rotating? Why put ‘falls in the elderly’, ‘senile gait’ and ‘volvular epilepsy’ in a glossary in which terms such as ‘yaw, pitch and roll’ are much more appropriately defined? I also advise anyone who purchases this book to make sure that it is tightly and cleanly bound. The copy sent to me showed signs of crumbling. I hope this only reflected fortuitous damage in mailing.In some of the chapters, Brandt takes on problems that many clinicians prefer to avoid. The psychogenic aspects of dizziness and vertigo; psychogenic gait disorders; the controversies around perilymphatic fistulae and microvascular compression syndromes; migraine and vertigo; and autoimmune inner ear disease are all rationally discussed, and usually reflect the insightful investigations of Brandt and his colleagues. The entire section (about 100 pages) on nonvestibular vertigo is particularly helpful. Visual vertigo, motion sickness, cervical vertigo and the psychiatric syndromes are all given adequate treatment. One must acknowledge that this book is permeated with Brandt’s own opinions (though he certainly does not neglect to mention others), but when looked at critically, the majority of these ‘opinions’ have become the facts that we all use in our practices and in our teaching.Brandt’s approach is well illustrated from a conversation I had with him recently. His elderly Golden Retriever developed an acute unilateral vestibular syndrome and Brandt noticed that the dog had different strategies for maintaining balance when walking slowly and when running quickly. Immediately, a novel hypothesis emerged and Brandt ran back to the laboratory, retrieved the video camera and planned appropriate experiments with (human) patients. I am sure the results of this investigation will be in the next edition of his book. This anecdote reflects the philosophy underlying Brandt’s book: it combines science and clinical practice so that we not only bring science to the bedside but also let our patients teach us how the brain works.