Thalamic versus midbrain tremor; two distinct types of Holmes' Tremor: a review of 17 cases.

INTRODUCTION: Holmes Tremor (HT) is a unique and debilitating movement disorder. It usually results from lesions of the midbrain and its connection but can also result from posterior thalamic injury. Clinical examination can help lesion localization between these two areas. We studied the clinical features and their radiological correlations to distinguish midbrain HT (HT-m) from thalamic HT (HT-t). METHODS: Retrospective review of 17 patients with a HT-type presentation was conducted. Tremor characteristics, associated clinical signs and radiological findings were studied. RESULTS: Eleven patients had a myorythmic rest tremor, large amplitude proximal tremor with goal-directed worsening, with or without mild distal dystonic posturing, representing HT-m. Six patients had slow, large amplitude proximal tremors and distal choreathetoid movements, significant proximal/distal dystonic posturing, associated with proprioceptive sensory loss, representing HT-t. Haemorrhagic lesions were the predominant cause of HT-m; whereas, ischaemia was more commonly associated with HT-t. CONCLUSION: When assessing patients with HT, attentiveness to the presence of associated signs in the affected limb, such as a proprioceptive sensory deficits and additional movement disorders, can aid lesion localisation, which can have implications for management.

He drove forward with a yell: anger in medicine and Homer.

We use Homer and Sun Tzu as a background to better understand and reformulate confrontation, anger and violence in medicine, contrasting an unproductive 'love of war' with a productive 'art of war' or 'art of strategy'. At first glance, it is a paradox that the healing art is not pacific, but riddled with militaristic language and practices. On closer inspection, we find good reasons for this cultural paradox yet regret its presence. Drawing on insights from Homer's The Iliad and The Odyssey, we argue for better understanding of confrontation, anger, bullying, intimidation and violence in medicine in order to change the culture. For example, equating medicine with war is not a given condition of medicine but a convenient metaphor with historical origins and a historical trajectory. Other, non-martial metaphors, such as medicine as collaboration, may be more appropriate in an age of team-based care. Taking lessons from Homer, we suggest three key ways in which cold-hearted confrontation and anger in medicine can be transformed into productive, warm-hearted engagement: the transformation of angry impulse into (1) reflection, (2) moral courage and (3) empathy. Thinking with Homer can offer an aesthetically and morally charged alternative to the current body of literature on topics, such as anger in doctors, and how this may be 'managed', without recourse to an instrumental economy where emotions are viewed as commodities, and emotional responses can be 'trained' through communication skills courses.

The death of Hector: pity in Homer, empathy in medical education.

Empathy is thought a desirable quality in doctors as a key component of communication skills and professionalism. It is therefore thought desirable to teach it to medical students. Yet empathy is a quality whose essence is difficult to capture but easy to enact. We problematise empathy in an era where empathy has been literalised and instrumentalised, including its measurement. Even if we could agree a universally acceptable definition of empathy, engendering it in the student requires a more subtle approach than seems the case currently. We therefore examine this modern concept and compare it with others such as pity and compassion, using the medium of Homer's Iliad. Two famous scenes from the Iliad elicit pity in the characters and the audience. Pity and compassion are, however, given a complexity within the narrative that often seems lacking in modern ways of conceptualising and teaching empathy.

Putting it bluntly: communication skills in the Iliad.

In current undergraduate medical curricula, much emphasis is placed on learning the skills of communication. This paper looks at Homer's Iliad and argues that from it we may learn that our skills can be mechanistic, shallow and simplistic. Homer was regarded in the Greek and Roman world as the father of rhetoric. This reputation rested greatly on book 9 of the Iliad, the embassy from the Greek leaders to the bitter, wrathful Achilles. The mission of the three emissaries is to persuade him to return to the ranks of the Greeks, who are being routed since his refusal to fight. We learn how the outcome of a conversation may be predetermined by the previous relationship of the speakers, and how a man beyond reason responds to reason; we should reflect that Homer's audience heard the piece knowing the outcome, giving it a tragic inevitability. We, the audience, cannot analyse the discourse rationally, because in this, as in all communication, reason is disturbed by emotion.