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J Neurol (2004) 251 : 118–119 DOI 10.1007/s00415-004-0309-3

L. R. Caplan

Charles Franklin Hoover (1865–1927)

JON 1309

Received: 12 September 2003 Accepted: 23 October 2003 L. R. Caplan, M.D. (
) Division of Cerebrovascular Diseases Dept. of Neurology Beth Israel Deaconess Medical Center 330 Brookline Avenue Boston, MA 02215, USA E-Mail: [email protected]

PIONEERS IN NEUROLOGY

Charles Franklin Hoover (1865–1927)

Most neurologists are well aware of Hoover’s sign [1] and use it routinely as a marker of hysterical or feigned leg weakness. “If a normal person, lying on a couch in the dorsal position, be asked to lift the right foot off the couch with the leg extended, the left heel will be observed to dig into the couch as the right leg and thigh are elevated. If you place your hand under the tendo Achilles of the left side and sense the muscular resistance offered by the left leg you will observe that the left heel is pressed on to the couch with the same force which is exhibited in lifting the right leg off the couch. In other words, the left heel is employed to fix a point of opposition against the couch during the effort to lift the right leg. This will always occur if the healthy person makes a free and uninhibited effort to lift the right leg.” Hoover used only clinical observation to confirm the utility of his sign. Arieff and colleagues later tested the specificity of Hoover’s sign by comparing electrophysiological responses in patients with hemiplegia and sciatica with those elicited in patients with likely functional lower extremity weakness who had a positive Hoover’s sign and affirmed the validity of the sign [2]. But who was Hoover and what was the context in which he developed his sign [3–5]? Charles Franklin Hoover was

born in Miamisburg Ohio in 1865. His father was of Swiss-German and his mother of Dutch lineage. His father was a rather wealthy manufacturer of farm machinery. His family was religious and Charles originally studied to become a Methodist minister, but, owing to the influence of relatives who were physicians, he decided to become a doctor. He first attended Ohio Wesleyan University from 1882–1885 but later transferred to Harvard University where he received his Bachelor of Arts degree in 1887 and his medical degree in 1892. From 1890–1894 he, like some wealthy American students of that era, spent time in fashionable academic centers in Europe. He worked under Professor Edmond von Neusser at the University of Vienna and Professor Frederick Kraus at the University of Strassburg. At one time he also spent time in Paris at the Clinic of Pierre Marie. His experiences in the medical environment of Vienna and Paris exposed him to schools that at that time harbored the strong influence of Skoda and Laennec-masters and innovators in physical diagnosis. This European exposure during his formative medical education explains his lifelong devotion to honing his skills in physical diagnosis and teaching these skills to young students and physicians. In 1894 a visit to Cleveland led to his assuming the directorship of the

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summer medical classes at the City Hospital. His appeal was so great as a skilled and enthusiastic teacher that, at the suggestion of his pupils, he was appointed teacher of physical diagnosis and visiting physician to the Cleveland City Hospital. In 1907 he was appointed Professor of Medicine in the Medical College of Western Reserve University and visiting physician to the Lakeside Hospital. During World War I he served as a Major in the Medical Reserve Corps and was stationed at a Base Hospital Unit #4 in France in 1917. Hoover applied a scientific approach to examination of patients. His interests were rather diverse and included hematology, cardiology, neurology and respiratory diseases. He became especially proficient concerning the physical diagnosis of lung diseases. Another Hoover’s sign concerned movement of the costal margins in emphysema and other pulmonary disorders. He became very well known for his skills in physical diagnosis and for his teaching abilities and was appointed the first full-time Professor of Medicine at Western Reserve University serving from 1925 until his death in 1927. Hoover’s studies in Germany also introduced him to physiological chemistry and experimental research. He set up an experimental biochemical laboratory in Cleveland and continued to perform bio-

chemical research during his career. His first love, however, was physical diagnosis. From the time of his German apprenticeship his approach to clinical problems was that of a thoughtful physiologist. His reputation was that of a very thorough diagnostician. He prided himself on being a bedside rather than a laboratory diagnostician who relied mostly on his eyes, hands, and other senses aided only by pocket instruments. His diagnoses were the results of careful bedside observation of the symptoms and physical signs of disease interpreted in the context of pathological physiology. He apparently also could be rather stubborn.When convinced of the soundness of his ideas he expressed them forcibly. He believed thoroughly in internal medicine and did not often seek surgical interventions for his patients. He was dubious that roentgenology would add to diagnosis and actively fought the introduction of x-rays into the hospitals in which he worked. He amassed an impressive collection of philosophical and theological texts in his own library and never came far away from his Methodist religious inclinations. Hoover was clearly from a different era. Armed with a classical education gained in Europe and the USA, he was a devotee of detailed clinical analysis and examination. His two major contributions were

physical signs. Even after his death the physical signs that he described continue to be cited in pulmonary medicine, neurology, and physical diagnosis texts. I feel an affinity toward Hoover sinse I too bridged epochs, training at a time when symptoms and signs and an understanding of pathology and pathophysiology reigned supreme. The introduction of CT in the 1970s and shortly thereafter MRI abruptly changed clinical medicine and neurology. Hopefully the discipline and attention to basics that Hoover so revered and taught will not be lost just because we have new technologies. The technologies elaborate on diagnostic hypotheses but do not substitute for thorough clinical encounters and thoughtful hypotheses about disease types and locations.

References 1. Hoover CF (1908) A new sign for the detection of malingering and functional paresis of the lower extremities. JAMA 51:746–747 2. Arieff AJ, Tigay EL, Kurtz JF, Larmon WA (1961) The Hoover Sign. Arch Neurol 5:673–678 3. Transactions of the Association of American Physicians 1928; 10 4. Brown KL (ed) (1977) Medicine in Cleveland and Cuyahoga County 1810–1976. Cleveland, Ohio: The Academy of Medicine of Cleveland 5. Who’s Who in America 1926–1927