JRSM >
Volume 99, Number 5 >
Pp. 219-220
Letters |
1 Chairman, Department of Neurology, Brigham and Women's Hospital, Boston, MA;
USA
2 Professor of Neurology, Harvard Medical School, MA; USA
3 Neurologist-in-Chief Caritas St Elizabeth Medical Center, MA; USA
4 Professor and Chairman, Department of Neurology, Tufts University School of
Medicine, MA, USA
Correspondence to: Dr M A Samuels E-mail: MSAMUELS{at}PARTNERS.ORG
Dr Saad Shafqat is incorrect in his assertion that localization in clinical neurology has been rendered outmoded by advances in technology.1
The advances of modern neurology are built on the assumption that the neurologist can make the correct diagnosis. We were present when one of the first computerized tomography scans of the brain was performed in the 1970s. Upon seeing these first clear images of the brain, Dr Raymond Adams declared that we were witnessing the introduction of a new tool into clinical neurology. That has certainly proved to be true, but imaging is still just a tool. The treatments for neurological disease that we now possess are also not ends in themselves. They are only part of the continuous, gradual development of knowledge about the nervous system needed to solve the really big problems in clinical neurology (e.g. epilepsy, paralysis, dementia, neoplasia, degenerative disease, and stroke).
The fundamental problem that arises in degrading the examination is that all clinical analyses risk starting from the wrong point. Mistaking weakness for ataxia, tremor for seizure, functional paralysis for genuine paralysis, root pattern sensory loss from that of nerve or spinal cord, aphasia from psychosis, dystonia from joint limitation, coma from catatonia, hip arthritis from lumbar radiculopathy, apraxia from confusion: not to mention distinguishing the various types of gait and dysarthrias, create endless and misplaced testing, the results of which are as useful as the original mistake in interpretation.
In our current practices, much of what we do is to take a careful history, examine the patient and put into proper perspective all of the imaging, genetic and other laboratory testing that may or may not bear on the patient's problem. Experienced experts can learn to apply the principles correctly yet rapidly in order to conform to the time constraints of modern neurological treatment. To abandon the principles of the neurological method is to risk transforming our learned profession into a rote trade.
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