Biller Jose - Demyers the Neurologic Examination : A Programmed Text

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This is the seventh edition of Dr. DeMyers textbook on The Neurologic Examination. It is the second under the stewardship of the current authors. When first published in 1994, Dr. DeMyer hoped it would fill a gap and function as a self-learning tool that combined with feedback from experienced clinicians and practice at the bedside, would improve the diagnostic skills of a student. It was never meant to be read, but in many respects it was a to-do book. It was the active doing or practicing the techniques that Dr. DeMyer felt would engage the student and facilitate learning rather than promote memorization. As bedside examination skills improve, ultimately patients would come to benefit.

Currently there is a tendency to undermine the benefits of the physical examination as a foundational skill in clinical diagnosis. Various explanations are given that include limitations of time, increased sensitivity of diagnostic tools or the fact that some physical examination skills or findings, have been shown to not be diagnostic at all. It is certainly true that there are some physical examination practices of only historical interest, but most of the skills in eliciting a history and a relevant physical examination remain critical to proper diagnosis. When properly performed, they provide valuable information to an underlying disease and interpretation of abnormal diagnostic test results often relies on physical examination findings. Finally, the physical examination is of enormous benefit in the effective use of these diagnostic tests and the elimination of unnecessary ones. So, far from being relegated to historical interest, these skills are as important in the development of a clinician as they are for the patients under their care.

We want to end this preface by again acknowledging Dr. William E. DeMyer as an esteemed colleague who demonstrated the highest qualities of a physician, master clinician, and teacher. The origin of this book, and the current authors intention, is to promote the value of a thoughtful physical examination and interpretation of those findings. We hope this book will fill such a role by becoming a virtual mentor that facilitates learning, through performing and interpreting physical examination findings. If the directions within this book are followed, not only will you benefit, but so will your patients and that is an ultimate responsibility that society expects of us. We hope you enjoy this excursion and we wish you the best as your careers unfold.

Jos Biller, MD
Gregory Gruener, MD
Paul W. Brazis, MD

The purpose of this textbook is threefold: (1) to teach how to conduct a neurologic examination, (2) to review the anatomy and physiology for interpreting the examination, and (3) to show which laboratory tests help to clarify the clinical problem. This is not a differential diagnosis text or a systematic description of diseases.

Anyone who sets out to write a textbook should place the manuscript on one knee and a student on the other. When the student squirms, sighs, or gives a wrong answer, the author has erred. He should correct it right then, before the ink dries. That is the way I have written this text, on the basis of feedback from the students.

The peril of student-on-the-knee teaching is that, even though the student moves his lips, the words and voice remain the teachers. To escape from ventriloquism, my text relies strongly on self-observation and induction. First, you learn to observe yourself, not as Narcissus, but as a sample of every man. Whenever possible, you study living flesh, its look, its feel, and its responses. Why study a textbook picture to learn the range of ocular movements when you can hold up a hand mirror? Why memorize the laws of diplopia if you can do a simple experiment on yourself whenever you need to refresh your memory? In the best tradition of science, these techniques supplant the printed word as the source of knowledge. The text becomes a way of extending your own perceptions, of looking at the world through the eyes of experience.

Because programmed instruction is the best way for the learner to judge whether learning has taken place, most of the text is programmed. The student is not abandoned to guess whether he has learned something; the program makes him prove that he has. Programming, if abused or overdone, becomes incredibly dull and unmercifully slow. The reader is required to inspect each grain of sand but should have been shown the whole shoreline at a glance. Some programs err by bristling with objectivity, causing one to ask, Isnt there a human being around here somewhere? Didnt someone think this, decide it, maybe even guess at it a little? For interludes, I use quotations, anecdotes, and poetry. I even stoop to mnemonics. Sometimes I cajole without pretending, as is customary in textbooks, that the pages have been purified, relieved of an author. I am very much here, poking my head out of a paragraph now and then or peering at you through an asterisk. When I see that you are weary from filling in blanks, I offer some whimsy. When you overflow with something to say, I ask for an essay answer. Sometimes you are invited to anticipate the text, to match wits against the problem without the spoon. At all times as you practice the neurologic examination, I stand at your elbow, guiding your moves and interpretations. You should be able to do an accomplished neurologic examination when you finish the book. And lastly, I include references. Only one reader in a hundred uses them? I am interested in him, too, in his precious curiosity.