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 teacher's.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, "Isn't there a human being around here somewhere? Didn't 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.
These then are the secrets: a lot of self-observation, a lot of programming, some irony and humor, a few editorials, and occasionally a summarizing paragraph, like this one. And as the leaven, lest they vanish from medical education, reminders of the bittersweet flowers of the mind, of tenderness, of understanding and compassion, like this stanza from Yeats, because it is perhaps all that should preface a text like this, into which I have poured the best teaching that I can offer; yet the wish always exceeds the result, ah me, by far:
Had I the heavens' embroidered cloths,
Enwrought with gold and silver light,
The blue and the dim and the dark cloths
Of night and light and the half light,
I would spread the cloths under your feet;
But I, being poor, have only my dreams;
I have spread my dreams under your feet;
Tread softly because you tread on my dreams.
To the many colleagues who have shared their knowledge with me over the years, I am deeply grateful. I especially want to thank Dr. Alexander T. Ross, my own preceptor in clinical neurology, and many friends in the basic disciplines of neurology, Drs. Ralph Reitan, Charles Ferster, Sidney Ochs,Wolfgang Zeman, and Jans Muller. For their day-to-day help I thank my wife,Dr. Marian DeMyer,Dr. Mark Dyken, and the many medical students, interns, and residents who suffered through the stuttering phases of the programming. I also thank Miss Irene Baird, who meticulously, maternally made the drawings; Mrs. Faith Halstead, who typed and retyped the burgeoning manuscript; medical artist James Glore; and photographer Joseph Demma.