Much progress has been made in the complementary investigation of patients with neurological
diseases in recent decades, particularly with the extraordinary advances in neuroimaging.
However, clinical neurological assessment (assessment of clinical history and neurological
examination) continues to be an essential activity and of the utmost importance11 Nicholl DJ, Appleton JP. Clinical neurology: why this still matters in the
21st century. J Neurol Neurosurg Pshychiatry. 2014;29. Online first.
http://dx.doi.org/10.1136/jnnp-2013-306881.
https://doi.org/10.1136/jnnp-2013-306881...
. The excessive importance attached to
complementary examination as a means of compensating for inadequate assessment of a patient’s
clinical history and an incomplete neurological examination has led to various problems in
clinical neurological practice11 Nicholl DJ, Appleton JP. Clinical neurology: why this still matters in the
21st century. J Neurol Neurosurg Pshychiatry. 2014;29. Online first.
http://dx.doi.org/10.1136/jnnp-2013-306881.
https://doi.org/10.1136/jnnp-2013-306881...
. It is
against this background that some findings have been highlighted in the neurological
literature. Callaghan et al.22 Callaghan BC, Kerber KA, Pace RJ, Skolarus LE, Burke JF. Headaches and
neuroimaging: high utilization and costs despite guidelines. JAMA Intern Med.
2014;174(5):819-21. http://dx.doi.org/10.1001/jamainternmed.2014.173
https://doi.org/10.1001/jamainternmed.20...
, for example,
recently investigated the relationship between complaints of headaches, which are particularly
common in daily clinical neurological practice, and the use of neuroimaging tests. They
reported that expensive neuroimaging tests are widely used despite the existence of multiple
guidelines recommending that these be used sparingly in routine assessments of patients with
complaints of headaches22 Callaghan BC, Kerber KA, Pace RJ, Skolarus LE, Burke JF. Headaches and
neuroimaging: high utilization and costs despite guidelines. JAMA Intern Med.
2014;174(5):819-21. http://dx.doi.org/10.1001/jamainternmed.2014.173
https://doi.org/10.1001/jamainternmed.20...
. Other important
findings related to the use of the ophthalmoscope during neurological examinations were
reported by Nicholl et al.33 Nicholl DJ, Yap CP, Cahill V, Appleton J, Willetts E, Sturman S. The TOS
study: can we use our patients to help improve clinical assessment? J R Col Physicians
Edinb. 2012;42(4):306-10. http://dx.doi.org/10.4997/JRCPE.2012.405
https://doi.org/10.4997/JRCPE.2012.405...
in the UK and
Bruce et al.44 Bruce BB, Lamirel C, Wright DW, Ward A, Helpern KL, Biousse V et al.
Nonmydriatic ocular fundus photography in the emergency department. N Eng J Med.
2011;364(4):387-9. http://dx.doi.org/10.1056/NEJMc1009733
https://doi.org/10.1056/NEJMc1009733...
in the USA. In the British
study, 48% of patients who had been referred to a neurologist had not been examined with an
ophthalmoscope, while in the American study only 14% of patients seen in an emergency service
(most of whom presented with complaints of headaches) had been examined with one33 Nicholl DJ, Yap CP, Cahill V, Appleton J, Willetts E, Sturman S. The TOS
study: can we use our patients to help improve clinical assessment? J R Col Physicians
Edinb. 2012;42(4):306-10. http://dx.doi.org/10.4997/JRCPE.2012.405
https://doi.org/10.4997/JRCPE.2012.405...
,44 Bruce BB, Lamirel C, Wright DW, Ward A, Helpern KL, Biousse V et al.
Nonmydriatic ocular fundus photography in the emergency department. N Eng J Med.
2011;364(4):387-9. http://dx.doi.org/10.1056/NEJMc1009733
https://doi.org/10.1056/NEJMc1009733...
. This intriguing situation is reflected in an ironic editorial
written by Prof. C. H. Hawkes in Practical Neurology under the title I’ve stopped
examining patients!55 Hawkes CH. I´ve stopped examining patients. Pract Neurol. 2009;9(4):192-4.
http://dx.doi.org/10.1136/jnnp.2009.181958
https://doi.org/10.1136/jnnp.2009.181958...
. An adequate clinical history and correct neurological examination are
still considered the cornerstones of clinical neurology. Nicholl and Appleton11 Nicholl DJ, Appleton JP. Clinical neurology: why this still matters in the
21st century. J Neurol Neurosurg Pshychiatry. 2014;29. Online first.
http://dx.doi.org/10.1136/jnnp-2013-306881.
https://doi.org/10.1136/jnnp-2013-306881...
concluded, in a recently published article,
that even in the modern era wider dissemination of the essential neurological skills is
required to ensure more thorough investigation and better care of patients with neurological
diseases. In this edition of Arquivos de Neuro-Psiquiatria, Maranhão-Filho et
al.66 Maranhão-Filho P, Vincent MB, Martins da Silva M. Neurological examination:
pioneering authors and their books. Arq Neuropsiquiatr. 2015;73(2):140-146.
http://dx.doi.org/10.1590/0004-282X20140215
https://doi.org/10.1590/0004-282X2014021...
, from the Neurology Service at the
Hospital de Clínicas Clementino Fraga-Filho, Federal University of Rio de
Janeiro, present an interesting review of neurological examination, with an emphasis on
pioneering authors and their books. They provide a brief introduction to the most important
textbooks that seek to disseminate the teaching of neurological examination and their
respective authors66 Maranhão-Filho P, Vincent MB, Martins da Silva M. Neurological examination:
pioneering authors and their books. Arq Neuropsiquiatr. 2015;73(2):140-146.
http://dx.doi.org/10.1590/0004-282X20140215
https://doi.org/10.1590/0004-282X2014021...
. Among 19th
century works, they discuss the books of pioneering authors in the field of neurology such as
Hammond, Gowers and Mills, and in the 20th century they focus on the books of
Monrad-Krohn, Denny-Brown, Wartemberg, Holmes and DeJong, as well that by the only Brazilian
author included in the review, Aloysio de Castro66 Maranhão-Filho P, Vincent MB, Martins da Silva M. Neurological examination:
pioneering authors and their books. Arq Neuropsiquiatr. 2015;73(2):140-146.
http://dx.doi.org/10.1590/0004-282X20140215
https://doi.org/10.1590/0004-282X2014021...
. Jean-Martin Charcot, the founding father of modern neurology,
developed the renowned clinical-pathological method based on the studies of Laennec and his
famous méthode anatomo-pathologique. However, Charcot did not publish any
books on neurosemiology. One of the pioneering books in this field was A Manual of the
Nervous Diseases of Man, by Moritz Romberg, which was published in English in
185377 Keppel-Hesselink JM, Koehler PJ. Romberg´s sign. In: Koehler PJ, Bruyn GW,
Pearce JMS. Neurological eponyms. Oxford: Oxford University Press; 2000.
p.166-71.. This exerted a great influence not
only in Germany, but also in other European countries, particular the United Kingdom77 Keppel-Hesselink JM, Koehler PJ. Romberg´s sign. In: Koehler PJ, Bruyn GW,
Pearce JMS. Neurological eponyms. Oxford: Oxford University Press; 2000.
p.166-71.. A general analysis of the books on
neurosemiology highlighted by Maranhão-Filho et al. reveals the influence of three important
schools of neurology: the French, the English and the American66 Maranhão-Filho P, Vincent MB, Martins da Silva M. Neurological examination:
pioneering authors and their books. Arq Neuropsiquiatr. 2015;73(2):140-146.
http://dx.doi.org/10.1590/0004-282X20140215
https://doi.org/10.1590/0004-282X2014021...
. The last of these, represented by the books of William A. Hamond,
Charles K. Mills, Derek E. Denny-Brown, Russel N. DeJong and Robert Wartemberg, was also
greatly influenced by English and French neurology66 Maranhão-Filho P, Vincent MB, Martins da Silva M. Neurological examination:
pioneering authors and their books. Arq Neuropsiquiatr. 2015;73(2):140-146.
http://dx.doi.org/10.1590/0004-282X20140215
https://doi.org/10.1590/0004-282X2014021...
. British neurology made a significant contribution to neurosemiology
with the publication of books by Sir William R. Gowers and Gordon M. Holmes66 Maranhão-Filho P, Vincent MB, Martins da Silva M. Neurological examination:
pioneering authors and their books. Arq Neuropsiquiatr. 2015;73(2):140-146.
http://dx.doi.org/10.1590/0004-282X20140215
https://doi.org/10.1590/0004-282X2014021...
. Professor Georg H. Monrad-Krohn, from Norway,
published the famous Blue Book of Neurology, which became known as
The Blue Bible, and was much influenced by English neurology after studying
at Queen Square Hospital66 Maranhão-Filho P, Vincent MB, Martins da Silva M. Neurological examination:
pioneering authors and their books. Arq Neuropsiquiatr. 2015;73(2):140-146.
http://dx.doi.org/10.1590/0004-282X20140215
https://doi.org/10.1590/0004-282X2014021...
. Aloysio de Castro,
considered the pioneer of neurosemiology in Brazil, was greatly influenced by French
neurology, particularly by professor Pierre Marie, a fervent disciple of Charcot, at the
famous Salpêtrière Hospital in Paris88 Maranhão-Filho P. Aloysio de Castro, the pioneer of neuro-semiology in
Brazil. Rev Bras Neurol. 2014;50(3):66-9.. Castro
published the famous book Tractado de Semiótica Nervosa, as well as a thesis
on gait disorders and their semiological value, which was published in 190466 Maranhão-Filho P, Vincent MB, Martins da Silva M. Neurological examination:
pioneering authors and their books. Arq Neuropsiquiatr. 2015;73(2):140-146.
http://dx.doi.org/10.1590/0004-282X20140215
https://doi.org/10.1590/0004-282X2014021...
,88 Maranhão-Filho P. Aloysio de Castro, the pioneer of neuro-semiology in
Brazil. Rev Bras Neurol. 2014;50(3):66-9.. The important pioneering contributions of the various authors
mentioned by Maranhão-Filho et al.66 Maranhão-Filho P, Vincent MB, Martins da Silva M. Neurological examination:
pioneering authors and their books. Arq Neuropsiquiatr. 2015;73(2):140-146.
http://dx.doi.org/10.1590/0004-282X20140215
https://doi.org/10.1590/0004-282X2014021...
in in the
field of neurological examination should serve as examples and a stimulus for younger
neurologists so that they may constantly improve the clinical examination of neurological
patients as well as reduce costs during this period of great technological advances. The
correct application of neurosemiology and recognition of its importance can not only be
invaluable in reducing “neurophobia”99 Jozefowicz RF. Neurophobia: the fear of neurology among medical students.
Arch Neurol. 1994;51(4):328-9.
http://dx.doi.org/10.1001/archneur.1994.00540160018003
https://doi.org/10.1001/archneur.1994.00...
among
medical students, but also stimulate a new syndrome characterized by a fascination with
neurology, known as “neurophilia”1010 Fuller GN. Neurophilia: a fascination for neurology - a new syndrome. Pract
Neurol. 2012;12(5):276-8.
http://dx.doi.org/10.1136/practneurol-2012-000400
https://doi.org/10.1136/practneurol-2012...
.
References
-
1Nicholl DJ, Appleton JP. Clinical neurology: why this still matters in the 21st century. J Neurol Neurosurg Pshychiatry. 2014;29. Online first. http://dx.doi.org/10.1136/jnnp-2013-306881.
» https://doi.org/10.1136/jnnp-2013-306881 -
2Callaghan BC, Kerber KA, Pace RJ, Skolarus LE, Burke JF. Headaches and neuroimaging: high utilization and costs despite guidelines. JAMA Intern Med. 2014;174(5):819-21. http://dx.doi.org/10.1001/jamainternmed.2014.173
» https://doi.org/10.1001/jamainternmed.2014.173 -
3Nicholl DJ, Yap CP, Cahill V, Appleton J, Willetts E, Sturman S. The TOS study: can we use our patients to help improve clinical assessment? J R Col Physicians Edinb. 2012;42(4):306-10. http://dx.doi.org/10.4997/JRCPE.2012.405
» https://doi.org/10.4997/JRCPE.2012.405 -
4Bruce BB, Lamirel C, Wright DW, Ward A, Helpern KL, Biousse V et al. Nonmydriatic ocular fundus photography in the emergency department. N Eng J Med. 2011;364(4):387-9. http://dx.doi.org/10.1056/NEJMc1009733
» https://doi.org/10.1056/NEJMc1009733 -
5Hawkes CH. I´ve stopped examining patients. Pract Neurol. 2009;9(4):192-4. http://dx.doi.org/10.1136/jnnp.2009.181958
» https://doi.org/10.1136/jnnp.2009.181958 -
6Maranhão-Filho P, Vincent MB, Martins da Silva M. Neurological examination: pioneering authors and their books. Arq Neuropsiquiatr. 2015;73(2):140-146. http://dx.doi.org/10.1590/0004-282X20140215
» https://doi.org/10.1590/0004-282X20140215 -
7Keppel-Hesselink JM, Koehler PJ. Romberg´s sign. In: Koehler PJ, Bruyn GW, Pearce JMS. Neurological eponyms. Oxford: Oxford University Press; 2000. p.166-71.
-
8Maranhão-Filho P. Aloysio de Castro, the pioneer of neuro-semiology in Brazil. Rev Bras Neurol. 2014;50(3):66-9.
-
9Jozefowicz RF. Neurophobia: the fear of neurology among medical students. Arch Neurol. 1994;51(4):328-9. http://dx.doi.org/10.1001/archneur.1994.00540160018003
» https://doi.org/10.1001/archneur.1994.00540160018003 -
10Fuller GN. Neurophilia: a fascination for neurology - a new syndrome. Pract Neurol. 2012;12(5):276-8. http://dx.doi.org/10.1136/practneurol-2012-000400
» https://doi.org/10.1136/practneurol-2012-000400
Publication Dates
-
Publication in this collection
Feb 2015
History
-
Received
05 Jan 2015 -
Accepted
15 Jan 2015