MATHEMAGICAL CLINICAL
NEUROLOGY
Prof.A.V.SRINIVASAN
M.D.D.M. Ph.D.F.I.A.N. F.A.A.N.
Additional Prof.of Neurology
Madras Institute of Neurology
TO TEACH IS AN HONOUR
THAT IS SACRED
MIN - MOTTO
Mathemagical Clinical Neurology
ABSTRACT
OBJECTIVE: To construct a teaching model for easier clinical neurological examination to
help the medical students and paramedical personal to understand the neuroanatomy
and etiopathological disorders of the nervous system.
BACKGROUND: Neurophobia is a fear of neural sciences and clinical neurology and half of
the medical students and paramedical personal experience this disorder during their
training. We have evolved an easy, faster ten step approach in clinical neurological
examination using mathematical numbers.
METHODS: One characterizes consciousness / mind, Two represents the two cerebral
hemispheres and Three, the major functions of the brain namely cognition, conation and
affect. Four represents the four lobes and four ventricles. Five represents five special
senses. Six explains the six major functional systems of the brain, basal ganglia
(programmer), cerebellum (computer), cerebral and its efferents (output), sensory
systems (input), autonomic nervous system (emergency situations) and the limbic
system (integrator of all). Seven characterizes the LMN (anterior horn cells anterior
nerve root posterior nerve root  peripheral nerve  neuromuscular junction 
muscle  intracellular organelles. Eight represents eight language disorders, four with
normal repetition and four with abnormal repetition. The Nine etiologies in fingertips
Thumb (Tumour, Toxin, Trauma), Index Finger (Infection), Middle finger (Metabolic),
Diamond finger (Demyelination), Little finger (vascular) and Hand (Hereditary and
nutritional disorders). Ten represents the ten pairs of cranial nerves with olfactory and
optic nerves, which are extensions of brain.
CONCLUSION: This faster and easier method of neurological examination will help the
epidemiological field workers. Ten step approach of clinical neurology teaching will
replace Neurophobia with Neurophilia, and will effectively integrate the basic sciences
with clinical neurology.
ALBERT EINSTEIN
EVERY THING SHOULD BE MADE
SIMPLE, BUT NOT SIMPLER
-
AIMS AND OBJECTIVES
To Evolve a teaching model for easier,
faster clinical neurological examination to
help the Neuroscientists including medical
students and paramedical personal to
understand
the
Neuroanatomy,
Neurophysiology and Etiopathological
approach of the nervous system.
BACKGROUND
Neurophobia is a fear of Neuro sciences and
clinical neurology. Most of the medical students and
paramedical personal experience this disorder during
their training. Physical examination in the chapter of the
nervous system in Hutchison’s Clinical methods 2002
W.B.Saunders,London, expanded more than 50% from
19,110 words to 29,632 words,while in Respiratory and
Cardiovascular system decreased by 47% and 70%
respectively when compared to the first edition of
clinical methods-A guide to the practical study of
medicine in 1897(Alisdair Mcneill-Practical
neurology,2005,5,180-3).Clinical evaluation of the
nervous system becoming too unwieldy for routine use
and certainly for the modern medical student
curriculum.We have evolved an easy, faster ten step
approach in clinical neurological examination using
mathematical numbers
MATHEMAGICAL CLINICAL
NEUROLOGY
ONE
-
CONSCIOUSNESS/MIND
TWO
-
CEREBRAL HEMISPHERES
THREE -
FUNCTIONS OF BRAIN
COGNITION
CONATION
AFFECT
FOUR
-
LOBES OF BRAIN
FIVE
-
SPECIAL SENSES
SIX
-
UPPER FUNCTIONAL MOTOR
NEURON SYSTEMS OF BRAIN
SEVEN
-
LOWER FUNCTIONAL MOTOR
NEURON SYSTEMS OF BRAIN
EIGHT
-
LANGUAGE DISORDERS
NINE
-
ETIOLOGY
TEN
-
TEN CRANIAL NERVES WITH
OLFACTORY AND OPTIC NERVES –
EXTENSIONS OF BRAIN
TEACHING METHODS-TEN STEPS
I AM HAPPY THAT PROF.A.V.SRINIVASAN HAS THOUGHT IT FIT TO
INTRODUCE A NEWER CONCEPT OF NEUROLOGICAL EXAMINATION
WHICH IS BASED ON AREAS OF ANATOMY AND FUNCTION IN A STEP
WISE FASHION STARTING AT THE CORTICAL LEVEL AND RIGHT DOWN
TO THE NEUROMUSCULAR LEVEL AND INCURS THE ABILITY TO
TRANSLATE THIS INTO A RESORTMENT PATTERN IN NEUROLOGICAL
INTERPRETATION.THIS IS A NEW CONCEPT WHICH,HE HAS ENTERED,
HAS DONE EXTREMELY WELL TO SHOW IT TO HIS COLLEAGUES.I AM
SURE THAT THE ARDENT GROUP OF STUDENTS OF NEUROLOGY AND
EVEN STUDENTS OF INTERNAL MEDICINE AND NEUROSURGEONS WILL
BENEFIT WITH THIS NEW TECHNIQUE,METHOD OF A WAY OF
EVALUATING NEUROLOGICAL DISEASES
Prof.K.V.THIRUVENGADAM
B.Sc,M.D.,D.Sc(hon).F.R.C.P(EDIN), FAMS,FCCP,FCAI
FORMER DIRECTOR OF MEDICINE
MADRAS MEDICAL COLLEGE AND GOVT.GENERAL HOSPITAL
CHENNAI,TAMIL NADU, INDIA
.
CLINICAL DIAGNOSIS IN NEUROLOGY IS USUALLY ARRIVED AT BY DETECTING SIGNS WHICH
INDICATE DISTURBANCE OF A FUNCTION IN THE CEREBRAL SPINAL AXIS.IN THE PRESENT SYSTEM
OF DIAGNOSIS,BY VIRTUE OF COMBINING POSITIVE SIGNS TO FIND A MEANINGFUL LOCATION IN
THE CENTRAL NERVOUS SYSTEM OR THE PERIPHERAL NERVOUS SYSTEM.THIS METHOD OF
ARRIVING AT CLINICAL DIAGNOSIS HAS STOOD THE TEST OF TIME BUT HAS AN INHERENT DEFECT
BEING TIME CONSUMING.
THE NEW SYSTEM BY VIRTUE OF DETECTING THE DEFECTS IN THE SYSTEM STRAIGHT WAY BY
VIRTUE OF THE SIGNS PICKED UP AT THE TIME OF THE EXAMINATION HELPS IN THE BEDSIDE
DIAGNOSIS EASIER AND QUICKER.ELECTROPHYSIOLOGICAL STUDIES AND IMAGING TECHNIQUES
ARE USED ONLY TO CONFIRM THE CLINICAL IMPRESSION GIVING EASIER RECOGNITION OF
ANATOMICAL LEVELS OF INVOLVEMENT.
DEMONSTRATION OF SOME OF THE CASES EXAMINED BOTH WAYS REVEAL THE ACCURACY OF
DIAGNOSIS MORE IN THIS SYSTEM AS AGAINST THE CONVENTIONAL ONE.
THIS SYSTEM WILL HELP LEARNING AND DIAGNOSING NEUROLOGICAL AILMENTS.IT IS BOTH
COMPLIMENTARY AND PRIMARY IN CLINICAL EXAMINATION AT THE BED SIDE PROBABLY GIVING A
BETTER INSIGHT TO THE STUDENT REGARDING THE FUNCTIONAL DERANGEMENT CORRELATING
WITH FUNCTIONAL ANATOMY AND WILL BE USEFUL IN EVALUATING NATURAL EVOLUTION OF
MANY NEUROLOGICAL DISORDERS.
WITH THE REDUCTION OF TIME IN THE PRIMARY AND FOLLOW UP EXAMINATION,PATIENT CARE
IMPROVES.THIS SYSTEM IS ALSO COMPUTER COMPATIBLE BY PROPER DATA COLLECTION AND
ANALYSIS. THIS SYSTEM WILL BE A GREAT BOON IN HELPING QUICKER AND MORE SPECIFIC
TREATMENT SCHEDULES.
Prof.K.JAGANNATHAN M.D.,D.T.M.,F.R.C.P.,F.A.M.S
Former Head and Prof. of Neurology
Madras Medical College and Govt.Gen.Hospital
Chennai,Tamilnadu, India
EXAMINATION OF
CONSCIOUSNESS(COMA)
GLASGOW COMA SCALE
EYE OPENING
SPONTANEOUS
TO LOUD VOICE
TO PAIN
NIL
RANCHO LOS AMIGOS
COGNITIVE SCALE
4
3
2
1
VERBAL RESPONSE
ORIENTED
CONFUSED,DISORIENTED
INAPPROPRIATE WORDS
INCOMPREHENSIBLE SOUNDS
NIL
5
4
3
2
1
MOTOR RESPONSE
OBEYS
LOCALIZES
WITHDRAWS(FLEXION)
ABNORMAL FLEXIONPOSTURE
EXTENSION POSTURE
NIL
6
5
4
3
2
1
NO RESPONSE
GENERALIZED RESPONSE
LOCALIZED RESPONSE
CONFUSED/AGITATED
CONFUSED- NOT APPROPRIATE
CONFUSED-APPROPRIATE
AUTOMATIC-APPROPRIATE
PURPOSEFUL-APPROPRIATE
1
2
3
4
5
6
7
8
LEFT
HEMISPHERE
(VERBAL)
ANALYSIS
DEDUCTION
FACTS
LOGICAL
ORDER
MATHEMATIC
PRACTICAL
RIGHT
HEMISPHERE
(VISUAL)
ARTISTIC
CREATIVE
HOLISTIC
INTUITION
IDEAS
IMAGINATION
SPATIAL
THREE FUNCTIONS
COGNITION -- Perception & Thinking
CONATION -- Movement
AFFECT
-- Motor expression of Emotions
EXAMINATION OF COGNITIVE DECLINE-DEMENTIA


IDEAL BED SIDE
MMSE
RESEARCH
ICD-10
DSM-IV
NINCDSADRDA
ADDTC-VASCULAR
DEMENTIA
CONATION –MOVEMENT
SECOND FUNCTION OF BRAIN

WHAT ARE THE MOVEMENTS?

IDENTIFY THE OVERALL SYNDROME.

DECIDE THE DISEASE.
AFFECT- MOTOR EXPRESSION
OF EMOTIONS
THIRD FUNCTION OF BRAIN
EXAMINATION
OBJECTIVE MEASUREMENT DIFFICULT,
SUBJECTIVE SCALES ARE AVAILABLE
NORMAL EMOTION
EMOTIONAL LABILITY
EMOTIONAL INCONGRUITY
FOUR
LOBES OF CEREBRUM
AND
FOUR VENTRICLES
EXAMINATION OF HIGHER
FUNCTIONS AND LOBAR FUNCTIONS
HIGHER FUNCTIONS
TRADITIONAL
FRONTAL LOBE
EXECUTIVE FUNCTION
EMOTIONAL RESPONSE
SOCIAL BEHAVIOUR
PARIETAL LOBE
CALCULATION
STEREOGNOSIS
SPATIAL ORIENTATION
TEMPORAL LOBE
AUDITORY PERCEPTION
MUSIC TONE SEQUENCES
OLFACTION
SPEECH
OCCIPITAL LOBE
VISION
FIVE
SPECIAL SENSES
SMELL
VISION
HEARING
TASTE
TOUCH
TRADITIONAL
UPPER MOTOR NEURON
SIX FUNCTIONAL SYSTEMS OF THE
BRAIN (ABOVE FORAMEN MAGNUM)
1. Basal ganglia – Programmer
TRADITIONAL
2. Cerebellum – Computer
SPINOMOTOR
3. Cerebral hemisphere &
SYSTEM
connections - effector system
4. Sensory System
5. Autonomic nervous system – flight or fight
6. Limbic system Holistic integrator of all
BASAL GANGLIA-INVOLUNTARY
MOVEMENTS
PLENTY OF MOVEMENTS
A THETOSIS
B ALLISMUS
C HOREA
D YSTONIA
E SSENTIAL TREMOR
F ASCICULATIONS
M YOCLONUS
PAUCITY OF MOVEMENTS
AKINETIC RIGID STATES
PARKINSONISM
DRUG INDUCED
IDIOPATHIC
WILSONS DISEASE
PROGRESSIVE SUPRANUCLEAR PALSY
MULTIPLE SYSEM ATROPHY
CORTICOBASAL DEGENERATION
HUNTINGTONS -JUVENILE VARIANT
NIEMMAN-PICK DISEASE TYPE C
CEREBELLUM-(computer)
FUNCTIONS-COORDINATION
GAIT
ANTERIOR LOBE
TRUNCAL
VERMIS
LIMBS AND LANGUAGE
HEMISPHERE
EYE MOVEMENTS
FLOCCULONODULAR LOBE
SIGNS OF CEREBELLAR
DYSFUNCTION
INCOORDINATION OF
EYE- NYSTAGMUS
HEAD-TITUBATION
SPEECH-DYSARTHRIA
TRUNK-ATAXIA
LIMB-ATAXIA
GAIT-ATAXIA
WRITING-MACROGRAPHIA
CEREBRAL HEMISPHERES
(key board)
MOVEMENT
- FRONTAL LOBE
SENSATION
-PARIETAL LOBE
MEMORY
AND HEARING
–TEMPORAL LOBE
VISION
- OCCIPITAL LOBE
FUNCTIONS OF
AUTONOMIC NERVOUS SYSTEM
SYMPATHETIC


HEART RATE INCREASED
PARASYMPATHETIC

HEART RATE DECREASED
BLOODPRESSURE INCREASED

BLOOD PRESSURE DECREASED
INCREASED BLADDER
SPHINCTER TONE

VOIDING (DECREASED TONE)

DECREASED BOWEL MOTILITY

INCREASED BOWEL MOTILITY

BRONCHODILATATION

BRONCHOCONSTRICTION

SWEATING

DECREASED SWEATING

PUPIL DILATATION

PUPIL CONSTRICTION

SEVEN LOWER MOTOR NEURON SYSTEMS

ANTERIORHORN CELL

ANTERIOR NERVE ROOT

POSTERIOR NERVE ROOT

PERIPHERAL NERVE

NEUROMUSCULAR JUNCTION

MUSCLE

INTRACELLULAR ORGANELLES
SPINAL CORD
SPASTICITY
WEAKNESS
FASCICULATIONS
EARLY BLADDER AND BOWEL
TROPHIC CHANGES
ANTERIOR NERVE ROOT
SEGMENTAL WEAKNESS
SEGMENTAL WASTING
POSTERIOR NERVE ROOT
PAIN
PARESTHESIA
NUMBNESS
LOWER MOTOR NEURON SYSTEMS-CONTD
4. PERIPHERAL NERVE
BILATERAL DISTAL SYMMETRICAL NUMBNESS AND
WEAKNESS WITH WASTING(NEUROPATHIC)
5. NEUROMUSCULAR JUNCTION
DIURNAL VARIATION WITH FATIGABILITY OF
MUSCLES
6. MUSCLE
BILATERAL SYMMETRICAL PROXIMAL MUSCLE
WEAKNESS AND WASTING( MYOPATHIC)
7. INTRACELLULAR ORGANELLES
MITOCHONDRIA, SARCOGLYCANS
EIGHT-LANGUAGE
DISORDERS OF LANGUAGE
ABNORMAL REPITITION

BROCAS APHASIA

WERNICKES APHASIA

GLOBAL APHASIA

CONDUCTION APHASIA
DISORDERS OF LANGUAGE
NORMAL REPITITION

TRANSCORTICAL
SENSORY
 TRANSCORTICAL
MOTOR
 ANOMIC
 ALEXIA
NINE –ETIOLOGIES
THUMB
-
TUMOR, TOXIN, TRAUMA
INDEX FINGER -
INFECTION
MIDDLE FINGER-
METABOLIC
DIAMOND FINGER- DEMYELINATION,DEGENERATION
LITTLE FINGER
-
VASCULAR
(LITTLE FLOW/ABSENT FLOW)
HAND
- HEREDITY AND NUTRITIONAL DISORDERS
TEN PAIRS OF CRANIAL NERVES
CRANIAL NERVES
III,IV,VI NERVES
V NERVE
- OCULAR MOVEMENTS
- FACIAL SENSATIONS
MUSCLES OF MASTICATION
VII NERVE
- MUSCLES OF FACIAL
IX AND X NERVE
-
XI NERVE
-
XII NERVE
-
EXPRESSION
SECRETORY FUNCTIONS
PALATAL AND
PHARANGEAL MUSCLES
STERNOMASTOID AND
TRAPEZIUS
TONGUE MOVEMENTS
MATHEMAGICAL CLINICAL
NEUROLOGY
ONE
-
CONSCIOUSNESS/MIND
TWO
-
CEREBRAL HEMISPHERES
THREE -
FUNCTIONS OF BRAIN
COGNITION
CONATION
AFFECT
FOUR
-
LOBES OF BRAIN
FIVE
-
SPECIAL SENSES
SIX
-
UPPER MOTOR NEURONS SYSTEMS
OF BRAIN
SEVEN
-
LOWER MOTOR NEURONS
SYSTEMS OF BRAIN
EIGHT
-
LANGUAGE DISORDERS
NINE
-
GENERAL PRAESENS AND OTHER
SYSTEMS
TEN
-
ETIOLOGIES
ACKNOWELDGEMENTS
OUR SINCERE THANKS TO THE HEAD OF
THE DEPARTMENT OF NEUROLOGY,
DIRECTOR OF INTERNAL MEDICINE OF
MADRAS MEDICAL COLLEGE AND ALL
THE FACULTY MEMBERS OF THE
DEPARTMENT OF NEUROLOGY AND
MEDICINE