Modern technologies have, to some degree, replaced the careful elicitation of neurological physical signs. Many 20th century texts and monographs were devoted to such clinical phenomena. Foremost among them were the assiduous writings of Robert Wartenberg who fled Hitler to enhance Neurology in San Francisco. His work and influences are outlined here.

There has been within recent years an interesting tendency to rely more and more on laboratory, mechanical and other such methods...at the expense of careful clinical observation.

Sir Gordon Holmes, in 1953 foreword to Wartenberg’s -Diagnostic Tests in Neurology

One characteristic of modern neurology is the facility afforded by many new technologies, which have led to advances in diagnostic precision and in etiology. Easily accessed technology has pushed aside many components of history-taking and the accurate elicitation of physical signs. Before modern imaging, neurologists were sedulous in seeking and devising physical signs to unmask precise anatomical localization and clues of pathogenesis. To this end, a multitude of papers and monographs were written. Assiduous examinations brought undoubted benefits to patients from a longer, more attentive connection with their doctors: rather than the familiar, hasty brush-off with “we will see what the scan shows.” Indeed, the Latin assiduus is derived from the verb assidēre “to sit beside.”

Amongst several acknowledged expert hunters for physical signs and authors of texts expounding neurological examination, was the textbook of WR Gowers (1845–1915), “A Manual of Diseases of the Nervous System” (1888), which contained descriptions of both neurological diseases and methods to elicit physical signs. This was succeeded by SA Kinnier Wilson’s (1878–1937) Neurology (1940). In the wake of these “neurology bibles,” texts devoted to physical signs emerged: Gordon Holmes’ (1876–1965) “Introduction to Clinical Neurology”; Paul Robert Bing’s (1878–1956) “A Textbook of Nervous Diseases”; Russell de Jong’s (1907–1990) “The Neurologic Examination”; Derek Denny-Brown’s (1901–1980) “Handbook of Neurological Examination and Case Recording”; and Edwin Bickerstaff’s (1920–2008) “Neurological Examination in Clinical Practice”. Moritz Romberg’s “A Manual of Nervous Diseases of Man” (1795–1873), and the Norwegian, Monrad Krohn’s “Clinical Examination of the Nervous System” (1884–1964) were other exemplary texts.

Generations of neurologists employed clinical methods and acquired an envied mystique for clinical skill.

Prominent amongst them was Robert Wartenberg’s (1919–1956) Diagnostic Tests in Neurology: a Selection for Office Use” (1953). Wartenberg was born in Grodno, Belarus (Fig. 1).

He studied Medicine and graduated from the University of Rostock, Germany in 1919, and worked at the University of Freiburg, where he became Professor of Neurology in 1933. His mentors included Max Nonne (1861–1959) and Otfrid Foerster (1873–1941).

He married Baroness Isabelle von Sazenhofen in 1929, but soon the Nazis’ virulent regime of anti-Semitism [1] forced him to flee Germany in 1935. After junior appointments in Neurology at the University of California, he was eventually appointed Clinical Professor of Neurology in 1952.

Wartenberg’s academic accomplishments were vast [2]. As a clinician, he was meticulous [3], his papers showing minutely observed and considered punctilious detail. This was reflected in his lucid, informative books [4]. He believed in a “sacred obligation” to his students, and his dramatic, enthusiastic lectures earned him the reputation as the best teacher in the School of Medicine [5].

Wartenberg published more than 150 scientific papers and four books: The Examination of Reflexes: A Simplification (1945) translated into seven languages; Hemifacial Spasm (1952); Diagnostic Tests in Neurology (1953); and Neuritis, Sensory Neuritis, Neuralgia (published posthumously, 1958).

His diverse contributions were principally of clinical phenomena. They included: Wartenberg’s reflex adduction of the thumb in corticospinal tract disorders, head dropping test and neck rigidity in Parkinson’s disease, the glabellar tap sign [6], the winking jaw (Marcus Gunn reflex) [7], hemifacial spasm, progressive facial hemiatrophy [8], associated movements in the oculomotor and facial muscles, the abduction assumed by the little finger in ulnar palsy or Wartenberg’s sign [9], Cheiralgia paresthetica (entrapment of the radial sensory nerve) known as Wartenberg’s syndrome [10], Brachialgia statica paresthetica: nocturnal arm dysesthesias (predating the carpal tunnel syndrome), Lasègue’s sign and Kernig sign, Historical notes, and many other shrewd observations and commentaries. His name is perpetuated by several eponyms including Wartenberg’s migratory sensory neuropathy, characterized by a benign, often remitting numbness in the distribution of one or multiple cutaneous nerves. The Wartenberg wheel was designed to test cutaneous sensitivity as it was rolled across the skin.

Louis D. Boshes described him as:

The Stormy Petrel of Neurology and the Rebel of Book Reviewers.…

This “Sherlock Holmes” in the discipline of neurology, always searching for truth accuracy and dependability of researcher, clinician or writer, advanced his endowment into book reviewing. His acrid criticism was accurate, for the succeeding edition always embodied all recommendations, but at all times everyone benefited from the Wartenberg warmth, for he never made enemies with his microscopic scrutiny of facts in his unique but complete review of a tome [11].

In 1925–1926, Wartenberg was a fellow of the Rockefeller Foundation and he worked under Harvey Cushing in Boston. Wartenberg became an honorary member of eight foreign societies including the German Neurological Society. The “Robert Wartenberg Lecture” of the American Academy of Neurology, which has been delivered by many neuroscientists of distinction, attests to his international repute. Macdonald Critchley remembered his practices in neurology as:

“…Highly finished miniatures, small masterpieces, which testified to his very great skill as a clinical observer. As a teacher he was quite outstanding and could be compared with some of the great exponents of the British school of clinical neurology.” Undergraduate students regarded him with the highest admiration, but also esteemed his personal qualities of benevolence and drollery [12].

After a long career in California, he died in 1956.

His death was reported as severing the end of the golden period of descriptive neurology.

There are no conflicting interests or financial support in this work.

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7.
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9.
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Sprofkin BE: Cheiralgia paresthetica; Wartenberg’s disease. Neurology 1954; 4: 857–862.
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