This Volume of Progress in Clinical Neurosciences brings to you a synthesized overview of clinically relevant topics in an easy-to-read format. It would enable both the practicing Clinician and the student in training to update their knowledge and apply it in day-to-day practice. The most significant advances in traumatic brain injury, pituitary adenomas, myasthenia gravis, epilepsy source localization, and poststroke rehabilitation have been addressed. The controversies regarding the management of low grade gliomas, solitary brain metastasis and optimal surgical approach to colloid cysts are discussed cogently. A systematic diagnostic approach to myelopathy and encephalopathy is illustrated. The future of neurosurgical education is simulation and there is a detailed explanation of this strategy. The importance and relevance of clinical examination in today's era of highly advanced diagnostic imaging cannot be understated and this has been put forth emphatically.

1. Section A
General Neurosciences
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2. 3
I had the good fortune of being at the National
Institute for Nervous Diseases (as it was then
named) at Queen Square for a year (1974–
1975). Dr. Godfrey Hounsfield had just intro-
duced the EMI scanner (named after Electric
and Musical Industries Ltd.) and it was in use
at Atkinson Morley’s Hospital in Wimbledon
and at Queen Square. Already, the senior clini-
cians at Queen Square were voicing concern.
The ease with which the living brain could now
be studied on the computer images was leading
to indiscriminate demands for scans after cur-
sory clinical assessment. Atrophy of the clinical
senses was greatly feared.
Since then we have seen the mushroom-
ing of magnetic resonance scanners, positron
emission tomography scanners, and a host
of other diagnostic devices capable of produc-
ing mind-blowing images showing the struc-
ture and function of the human brain and
spinal cord.
This chapter ponders the downside of these
unquestionable advances and urges careful
clinical examination and analysis before using
them (Fig. 1.1).
In doing so, this chapter attempts to put
into practice the prescription written in 1927
by Dr. Francis Peabody.1
It is probably fortunate that systems of edu-
cation are constantly under the fire of general
criticism, for if education were left solely in
the hands of teachers the chances are good
that it would soon deteriorate. Medical educa-
tion, however, is less likely to suffer from such
stagnation, for whenever the lay public stops
criticizing the type of modern doctor, the
medical profession itself may be counted on to
stir up the stagnant pool and cleanse it of its
sedimentary deposit. The most common
The Relevance of Clinical
Examination Today1
criticism made at present by older practition-
ers is that young graduates have been taught a
great deal about the mechanism of disease, but
very little about the practice of medicine—or,
to put it more bluntly, they are too “scientific”
and do not know how to take care of patients.
In the present instance we should substi-
tute “sophisticated tests” for “the mechanism
of disease.” If, perchance, you have not yet read
this classic article, I urge you to look for it in the
library and embrace the lessons taught by this
wise physician.
Dangers of a Slipshod
Examination
A cursory examination yields few clues to diag-
nosis and leads to the use of shotgun tests. As
with the actual shotgun, most of the pellets
Sunil K. Pandya
Fig. 1.1 Dr. Francis Peabody (1881–1927).
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3. General Neurosciences4
will be wide of the mark and miss the target.
Worse, you may hit innocent “lesions” with dis-
astrous results.
Let me give you an example of how tests can
be avoided using the “little gray cells.”2
Some years ago, while I worked at the King
Edward Memorial Hospital and its allied medi-
cal college in Mumbai as a neurosurgeon, I
received a phone call from a senior colleague in
the Department of Endocrinology. He was wor-
ried he might have suffered a stroke in his right
parasagittal parietal lobe a few minutes earlier.
He told me of how he had awakened as
usual, and after his bath and breakfast, got
dressed to come to hospital. As he descended
the stairs in his home, he noted the foot drop
on his left side.
He came over to our outpatient clinic at my
request. He was composed, narrated his history
without difficulty, and awaited recommenda-
tions for tests and treatment. His own diagnosis
would have necessitated urgent computed tom-
ography or magnetic resonance scanning and
preparations for lysing a presumed thrombus
using intravenous tissue plasminogen activator.
Examination showed a simple foot drop
with no other signs. The plantar response could
not be assessed but the ipsilateral knee reflex
showed no abnormality. The findings did not
appear to be the consequence of a stroke. I was
puzzled about the cause of his foot drop and
why it should occur while descending stairs.
I asked him if he could have inadvertently
exerted pressure over the lateral popliteal
nerve. After a little reflection he conceded that
it could have happened for he often slept on a
couch with his knee dangling over the edge of
the back of the couch. Yes, he had slept thus the
previous night. And yes, it was the knee on the
same side as the foot drop that had rested on
the back of the couch.
So that might explain the compression of
the nerve, but why should the foot drop while
descending stairs.
Examination had shown weakness of the
extensors of the toes and foot but some power
persisted. A thought came to mind and I looked
at his shoes. They were somewhat heavy. I asked
him to walk on the level floor of the clinic with-
out the shoes. Did the foot drop persist? His face
was filled with surprise. “The foot is much bet-
ter. The weakness is much less marked.”
He was now asked to put on his shoes and
repeat the walk. “Ah! It is difficult to keep the
foot up when stepping with the shoes on.”
I now asked him to descend the stairs out-
side the clinic and could almost hear “Eureka!”
going through his mind as relief flooded his
face.
Subsequent examination by our neurophy-
sician and electrophysiological examination
confirmed incomplete paralysis of the lateral
popliteal nerve, most likely from pressure.
Helped by physiotherapy, he recovered com-
pletely over the next few weeks.
Current high resolution scanners show us a
wide range of variations in anatomy and physi-
ology. On several occasions, these are not the
cause of the patient’s symptoms and, left alone,
may do no harm. If, however, we have no clue as
to the possible diagnosis, we may fasten on to
them, investigate by further tests and even oper-
ate upon them without any benefit and some
risk to the patient. The presence of a parasagit-
tal meningioma measuring 1.5 cm in a 70-year-
old patient with limb weakness is an example.
Careful clinical examination would have shown
spondylotic myelopathy as the culprit.
We are being made increasingly aware of
the possible dangers of some tests. Medical
journals and the media express concern about
the radiation risks from tests such as repeated
computed tomography scans.
Listening to the Patient
Sir William Osler (Fig. 1.2), who ended his
career as Regius Professor of Medicine at
Oxford, kept emphasizing to his students, “Lis-
ten to your patient, he is telling you the diag-
nosis.”3
Indeed, when treating patients with
diseases of the nervous system, the detailed
history, obtained painstakingly, more often
than not, yields the diagnosis.
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4. 5The Relevance of Clinical Examination Today
Unfortunately, listening requires time and
effort. The chaff has to be separated from the
grains and the clinician must overcome irrel-
evant digressions, emphasis by the patient on
points that are of little significance and at times,
the offering of diagnoses by friends and relatives
and concealment of information. The rewards
outweigh the expenditure of time and effort.
My teachers have taught me to analyze
the details gathered after concluding the ses-
sion on history-taking and arriving at tentative
conclusions on the nature and location of the
disease. This has proved extremely useful and
has focused examination of the patient so that
further vital clues are unearthed.
The Clinical Examination
A gentle, thorough, and unhurried examina-
tion elicits data that supplement information
learned while taking the history. Subtle signs
provide vital clues to localization of disease.
The differentiation between disease originating
in the brain and that in the spinal cord can, at
times, be difficult and cannot be made only on
the basis of history. Failure to make the dis-
tinction can mean considerable expense to the
patient and delay in diagnosis and treatment.
The Analysis
Assessmentoftheinformationgatheredbyexam-
ination may lead to modification or even change
in the diagnosis made after taking the history.
Certainly, the mind is clearer on the likely cause
and site of the disease troubling the patient.
Based on this assessment it is possible to
discuss the likely diagnosis with the patient.
This can often help assuage the anxiety that has
troubled the patient since the awareness of an
illness. The likelihood of a self-limiting condi-
tion that needs no tests and simple treatment
lifts a huge burden. The possibility of spondy-
lotic myelopathy or a benign tumor amenable
to surgery similarly helps ridding the patient of
worry of dreaded malignant cancer.
This discussion paves the way for identifica-
tion of tests and an explanation of the rationale
for them.
There is another important consequence.
Taken together, history-taking and the exami-
nation add to the building of the doctor–patient
relationship and healthy interaction with wor-
ried family members. Witness to the care and
concern displayed by the clinician, the patient,
and family members develop faith. Faith is the
vital ingredient that cements trust in the doc-
tor and is a keystone in the care of the patient.
Assistance to Those
Performing Tests
The provision of information gained from his-
tory and examination and the subsequent anal-
ysis by the clinician that led to a provisional
diagnosis is invaluable to those performing
the special tests requested. Dr. Anisha Tandon
makes an impassioned statement.
Fig. 1.2 Sir William Osler (1849–1919).
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5. General Neurosciences6
We radiologists are familiar with the experi-
ence of having to report radiological studies
with absolutely the bare minimum clinical
history or the complete lack of it. But what
has begun to shake me to the core is the fact
that even when I have gotten back to the refer-
ring clinician for more information, there have
been innumerable instances where they sim-
ply do not know more just because they have
not really talked to the patient in detail, leave
alone examined the patient.
She goes on to describe a patient referred
to her “to exclude cerebral venous thrombo-
sis.” Her findings showed metabolic encepha-
lopathy. Subsequent tests showed a probable
cancer in a cirrhotic liver and ascites—not iden-
tified on clinical examination.4
Do Other Factors Play a Role?
Dr. Tandon’s experience, referred to above,
makes one ponder the reasons for jettisoning
the invaluable heritage of meticulous clinical
examination. Dr. Ingelfinger, the much-
respected editor of the New England Journal
of Medicine, felt that the personal encounter
between the patient and the physician can be
marred by authoritarianism, paternalism, and
dominance coupled with arrogance on the part
of the latter. In his posthumous essay titled
Arrogance he provided a personal example of
the suffering caused by such behavior on the
part of his medical attendants.5
Conclusion
There was a time when physicians prided them-
selves on their powers of observation and deduc-
tion. Sir Arthur Conan Doyle modeled Sherlock
Holmes on his teacher, Dr. Joseph Bell (Fig. 1.3).
The oft-narrated anecdote will bear repeti-
tion: On one occasion Doyle witnessed Bell tell-
ing students that a new patient walking into the
outpatient clinic was a recently discharged non-
commissioned officer who had been serving in
a Highland regiment stationed in Barbados.
Bell went on to explain,
You see gentlemen, the man was respectful
but did not remove his hat. They do not in the
army, but he would have learned civilian ways
had he been long discharged. He has an air of
authority and is obviously Scottish. As to Bar-
bados, his complaint is elephantiasis, which is
West Indian, and not British.6
We need to bring back into the medical cur-
riculum and into our own practices the art of
observation, listening, and the careful exami-
nation of the patient.
Dr. Bell, himself, was concerned about the
development of these in impressionable medi-
cal students.
In teaching the treatment of disease and acci-
dent, all careful teachers have first to show
the student how to recognize accurately the
case. The recognition depends in great meas-
ure on the accurate and rapid appreciation of
small points in which the diseased differs from
the healthy state. In fact, the student must be
taught to observe. To interest him in this kind
Fig. 1.3 Dr. Joseph Bell (1837–1911).
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6. 7The Relevance of Clinical Examination Today
of work we teachers find it useful to show the
student how much a trained use of the obser-
vation can discover in ordinary matters, such
as the previous history, nationality, and occu-
pation of a patient.
He made these suggestions before the dis-
covery of X-rays by Roentgen. They are even
more relevant today.
Closer interaction between physician and
patient at all stages of care can be placed on a
firm footing by the concern shown during the
first encounter; and what better way is there of
showing such concern than by taking a careful
and unhurried history and carrying out a thor-
ough physical examination? These benefit both
the patient and the physician.
References
1. Peabody FW. The care of the patient. JAMA 1927;88:
877–882
2. Hercule Poirot. http://en.wikipedia.org/wiki/
Hercule_Poirot Accessed September 19, 2013
3. Osler William. http://open.salon.com/blog/
amytuteurmd/2008/11/19/listen_to_your_patient
Accessed September 17, 2013
4. Tandon Anisha Sawkar. The vanishing art of clinical
science – hyposkilia. http://radiologystories.com/
2013/06/03/the-vanishing-art-of-clinical-science-
hyposkilia/ Accessed July 8, 2013
5. IngelfingerFJ.Arrogance.NEnglJMed1980;303(26):
1507–1511
6. Anonymous.TherealSherlockHolmes?http://www.
sherlockandwatson.com/the%20real%20sherlock
%20holmes.html Accessed September 19, 2013
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