Dystonic Tremor: Time to Change.

BACKGROUND: The term dystonic tremor is being increasingly used in neurological publications despite uncertainties about its meaning. We provide here a historical reconstruction from its original introduction in 1984 to help distinguish dystonia from essential tremor. METHODS: A comprehensive Pubmed search of MeSH terms "dystonia", "tremor", and "essential tremor" provided the information base for reconstructing historical usage of the term "dystonic tremor". RESULTS: Over the years, this expression was enriched of additional meanings and sided by companion descriptors, such as tremor associated with dystonia. Dystonic tremor has been considered characteristically coarse, jerky, irregular, directional and asymmetrical. These characteristics, however, are not included in the most recent definitions of tremor. The relationship between tremor and dystonia is not easy to untangle, as the two phenomena are often recognized in association. Tremor and dystonia experts have developed different visions of dystonic tremor that have been variably implemented. There are currently two independent consensus definitions, which are not coincident and imply different pathophysiological interpretations. CONCLUSIONS: This historical reappraisal highlights that usage of the expression dystonic tremor has evolved over time to lose its original meaning. Notwithstanding inconsistencies of current definitions, its usage has steadily increased and it is time now to agree on an updated terminology.

Considerations about the Neuropsychiatric Conditions of Quixote of La Mancha. / Consideraciones sobre las condiciones neuropsiquiátricas del Quijote de la Mancha.

Don Quixote of La Mancha, the picturesque character created by Miguel de Cervantes Saavedra in his immortal book The Ingenious Nobleman Sir Quixote of La Mancha, presents several neuropsychiatric conditions, including tremor, sleep disturbances, neuropsychiatric symptoms, syncope, perception disorders and traumatic brain injury. Throughout the masterpiece, there are episodes where the aforementioned disorders are evident. This paper makes a list of them and analyses them in the light of the current knowledge of those conditions.

Management of tremor in medieval Persia.

Tremor has been described in traditional systems of medicine throughout history. Persian medicine was one of those systems in medieval times and in it neurology and neurosurgery were also widely practiced and accepted. Based on the main Persian medical manuscripts, the current study focuses on the medieval concept of tremor as an important neurological disorder in order to clarify the development of neurology. Accordingly, three main approaches to the control and treatment of tremor in traditional Persian medicine are considered. First is lifestyle modification. The administration of simple medicines is the second, and the last is the application of compound medicines. Our study shows how much was known about tremor in traditional Persian medicine.

Milestones in tremor research.

Tremor is one of the most frequent movement disorders and covers a wide spectrum of entities summarized in the 1998 consensus statement of the Movement Disorder Society. Essential tremor and Parkinson tremor are most common and are also the most thoroughly studied. Major progress has occurred in the clinical semiology, neuroimaging, epidemiology, and pathophysiology of tremors. Pathology and genetic research are rapidly growing fields of study. Recently described tremor entities include orthostatic tremor, dystonic tremor, cortical tremor, and thalamic tremor. Treatment research methodology has improved substantially, but few double-blind controlled trials have been published. Deep brain stimulation is the most effective treatment for most tremors but is reserved for advanced cases.

Shaking up the Salpetriere: Jean-Martin Charcot and mercury-induced tremor.

OBJECTIVE: To analyze Jean-Martin Charcot's studies of mercury-induced tremor. METHODS: This study examines Charcot's original notes on mercury intoxication from the Bibliothèque Charcot, Paris, and his show-and-tell patient presentations that were hand-transcribed by his students and later published. RESULTS: Using his standard method of presenting multiple patients with a similar disorder side by side, Charcot assembled a series of patients with mercurial intoxication from the clinics of Paris. He emphasized the rest and action components of mercury-induced tremor and stressed the value of using graphical tremor recordings rather than relying only on visual observation. He drew attention to the importance of air ventilation to avoid intoxication and of removal from intoxicating environments. He distinguished the characteristics of mercury-induced tremor from tremor associated with Parkinson disease, multiple sclerosis, and general paresis. Based on the similar intention tremor in multiple sclerosis and mercury intoxication, human pathology studies in multiple sclerosis, and animal experiments with mercury, he suggested that axonal demyelination underlay this form of tremor in both conditions, the former restricted to the CNS and the second to peripheral nerves. CONCLUSIONS: These cases illuminate Charcot's diagnostic strategy and his reliance on the clinico-anatomic method to correlate pathology with clinical signs. Whereas much of Charcot's work emphasized hereditary etiologies of neurologic disease, these examples allow an understanding of his views on environmental factors in neurologic disorders as well as treatment strategies.

The untold neurological disease of Franklin Delano Roosevelt (1882-1945).

Conventional wisdom suggests that Franklin Delano Roosevelt died on 12 April 1945 aged 63 from a massive cerebral haemorrhage attributable to uncontrolled hypertension and atherosclerosis. Evidence from numerous reliable sources is presented, based largely on a constellation of previously unrecognized neurological symptoms including seizures, encephalopathy and hemianopia, supporting a scenario that, while indeed he suffered from severe cardiovascular disease, Roosevelt died from melanoma with the terminal event attributable to a metastatic lesion in the brain.

Unresolved issues relating to the shaking palsy on the celebration of James Parkinson's 250th birthday.

James Parkinson's Essay on the Shaking Palsy published in 1817 provided the first clear clinical description for the disorder now known throughout the world by his name. His primary reason for publishing his monograph shortly before his retirement from medical practice was to draw the medical profession's attention to a malady, which had not yet been defined as a nosological entity. He also hoped that the eminent anatomists of the day would be stimulated to elucidate the pathological lesion responsible for the clinical picture and that this in turn might lead to a rational cure. The concept of Parkinson's disease remains clinically based and successive generations of neurologists have refined and embellished Parkinson's seminal descriptions. Narrative accounts by affected individuals have also helped physicians understand what it is like to live with Parkinson's disease. For many years, the pathological hallmarks of Parkinson's disease were disputed and there were few clinico-pathological reports with adequate clinical description. However, most neurologists now link severe loss of nigral cells in the ventrolateral tier of the pars compacta of the substantia nigra with bradykinesia and the presence of Lewy bodies in a number of discrete brain stem and cortical regions with Parkinson's disease. There are many unanswered clinical questions relating to Parkinson's disease including the striking heterogeneity and frequent limb asymmetry. It also remains somewhat uncertain whether Parkinson's disease is ever truly unilateral by the time of clinical presentation and whether the hand rather than the foot is the most common site of onset. Hyposmia and visual hallucinations are helpful pointers in distinguishing Parkinson's disease from atypical Parkinsonism and should be specifically enquired about in the history. Simple reliable cultural-specific smell identification batteries are an urgent need and target of clinical research. It remains to be determined whether Alzheimer type dementia as opposed to a dysexecutive syndrome should be considered a part of Parkinson's disease and further detailed clinico-pathological correlative studies are needed. It is also unclear whether autosomal dominant monogenetic Parkinsonism due to synuclein or LRRK-2 mutations will prove to be identical clinically with Parkinson's disease and for the present it is wiser to regard Parkinson's disease as a sporadic disorder. Parkinson was an active political reformer and if alive today would certainly be campaigning to translate more effectively the rich seam of neuroscientific research of the last decade into therapeutic benefits for the rising number of people who are developing the shaking palsy as a result of increasing longevity in the developed world.

How to treat tremor.

This paper presents an example of 18(th) century medical thinking. The author, Dr Georg Ernst Stahl (1659-1734) was the founder of the phlogiston theory in the field of chemistry, a medical professor, and a court physician in Saxony and Prussia. His description includes a definition of tremor, the internal and external causes of tremor, the types of tremor, the diagnostic and prognostic signs, and the treatment. From a present (contemporary) point of view, some compounds that were then used in treatment may have had a limited therapeutic effect on some kinds of tremor. Protopin has an anticholinergic and GABA-ergic effect, and rhoeadin (tetrahydrobenzazepin) may have had an effect similar to that of neuroleptics. Nevertheless, it is not clear whether the recommended quantity of these compounds was sufficient for a clinical effect. Most of the prescribed drugs could only have had a placebo effect.