Articles – Page 74

Rabat Center

Following the accreditation of the Center of Rabat as a training center of African neurologists, the Department of Neurology at the Mohamed V University hosted Dr. Mohamed Albakay from Mali Sept. 9, 2014, as the first African intern.

Albakay received a grant from the World Federation of Neurology of 12,000 Euros to cover the stay in Rabat, the accommodation, a return ticket Bamako-Casablanca and health insurance.

Following the agreement between the WFN and the Moroccan Foundation Against Neurological Diseases, the scholarship of Albakay will be managed by the foundation.

Albakay has already begun his training in electromyography in the Department of Clinical Neurophysiology of the Hà´spital des Specialtés, headed by Prof. Rida Ouazzani. During this stage, he also experienced the expertise of the team in the diagnosis of myopathies and peripheral neuropathies.

The second part of the course will take place in the Department of Clinical Neurophysiology of Mohammed-V Military Hospital, headed by Prof. Hamid Ouhabi. This department is well known for its expertise in EEG, video EEG and in the treatment of epilepsy.

Albakay may participate in the various multidisciplinary staffs organized by our department.

Furthermore, the Moroccan Society of Neurology decided to support his participation to the Maghrebin Congress of Neurology that will be held Nov. 13-15, 2014, in Agadir.

Prof. Mustapha El Alaoui Faris, Department of Neurology and Neuropsychology, Mohamed-V University, Rabat, Morocco

Putting the Brain on the World Map

Report of a highly successful debut World Brain Day

By Mohammad Wasay, MD, FRCP, FAAN

Mohammad Wasay

The idea of World Brain Day received a lot of appreciation and enthusiasm since its approval by World Federation of Neurology (WFN). Time was short, and the task was huge but the Public Awareness Committee (PAC) and Grisold Wolfgang, secretary-general, WFN, worked over a three-month period to make it a success.

Developing a public message and theme was the foremost task. AAN’s palatucci list serve made it easier. Many slogans, themes and messages were discussed and finally PAC suggested a list of themes, logos, messages and publication material.

All member country delegates were sent a memo by President Raad Shakir regarding information and suggested activities for World Brain Day. World Neurology’s article on World Brain Day also created awareness and momentum for this day.

Publication material including banners, posters and brochures were designed by a professional team of an advertising agency. These materials were made available to all delegate societies by the WFN website. The WFN Facebook page actively posted these materials that were shared by thousands. The number of WFN Facebook page likes were increased by 500 percent over one month. A special post on our Facebook page was a specially recorded video briefing of World Brain Day by Shakir. This video was shared by thousands creating awareness about World Brain Day.

An international media agency was hired to prepare a press briefing and disseminated throughout world media in four languages (English, German, Spanish and French). It was additionally translated into Urdu, Arabic, Hindi and other local languages. July 22, 2014, was a memorable day for WFN in terms of media propagation. Hundreds of newspapers around the world published our press briefing in more than 10 languages. Radio and TV programs were produced and telecast.

Member societies played an exceptional role in the day’s success. Despite limited time, more than 50 member societies organized public awareness activities in their countries. These included press conferences, seminars, patient awareness activities, briefings to media, students and health care workers. The largest numbers of activities were organized in India, Turkey and Pakistan. In India, other professional organizations including epilepsy foundation and Indian Neurorehab society organized activities. A prominent feature of World Brain Day activity in Janakpuri Hospital, New Delhi (organized by M.M. Mehndiratta) was Skype address of Raad Shakir.

The highest impact of this day was created on social media. Many societies shared and posted the World Brain Day banner on their websites. The American Academy of Neurology posted World Brain Day info on its website and Facebook pages with thousands of sharing.

Activities were largely organized by WFN and member societies. Due to a shortage of time, we were not able to actively involve other professional organizations especially Brain Council and Brain Research Organizations, World Health Organization and affiliated organizations like UNICEF.

In my knowledge, none of world days have received so much attention and media coverage as World Brain Day in its debut year. Our goal is to establish it as a joint WFN-WHO day. That requires years of awareness and advocacy. We should start planning for 2015 World Brain Day now with a target to approach millions of people, thousands of doctors (especially neurologists) and hundreds of health care and government officials in 2015.

Wasay is a professor in the Department of Neurology, Aga Khan University, Karachi, Pakistan, and the chair, public awareness and advocacy committee, World Federation of Neurology.

54th International Neuropsychiatric Congress

Opening of the 54th International Neuropsychiatric Congress in Pula.

The 54th International Neuropsychiatric Pula Congress (INPC) was held in Pula June 18-21, 2014, under the auspices of the Croatian President of Republic Prof. Dr. Ivo Josipovi.

The organizers of the Congress are: Kuratorium International Neuropsychiatric Congress, Department of Medical Sciences of the Croatian Academy of Arts and Sciences, the Association of Neuropsychiatry and Zagreb’s Institute for the Culture of Health. It was endorsed by the World Federation of Neurology and supported by the European Psychiatric Association, the Central and Eastern European Stroke Society (CEESS) and International Interdisciplinary Medical Association of Russia. The main

President of the INPC Congress, Prof. Vida Demarin and Prof. Michael Chopp with his wife.

sponsors of the congress were the Ministry of Science, Education and Sports of the Republic of Croatian, City of Zagreb, City of Graz, and Istria County. There were more than 350 participants from Croatian, Albania, Austria, Bosnia and Herzegovina, Montenegro, Czech Republic, Greece, Iran, Italy, Ireland, Hungary, Macedonia, Germany, Poland, Romania, Russia, United States, South Korea, Slovenia, Serbia, Ukraine, United Kingdom.

The main theme of the congress was “Lifestyle and Prevention of Brain Impairment.” In addition to lectures on the main theme, there were numerous accompanying symposia, in particular: third European Summer School of Psychopathology, seventh International Symposium on Epilepsy, second Neuro-Interdisciplinary School, third Symposium on the Interface Providers in Neurorehabilitation, psychiatric symposia on the new Croatian law on the protection of persons with mental disorders, forensic psychiatry, ADHD, treatment of advanced Parkinson’s disease, the activities of the Association of Public Health “Andrija Stampar” in stroke prevention, a common approach to diagnosis, treatment and follow-up of Anderson Fabry’s disease in

Prof. Vida Demarin with representatives of the Association of Public Health “Andrija Å tampar.”

South-East European region, cerebral aneurysms, palliative care and atrial fibrillation as a risk factor for stroke. A joint meeting with Alps-Adria Neuroscience Section, WFN Applied Research Group on the Organization and Delivery of Care and Central and Eastern European Stroke Society was held dealing with different therapeutic approaches in the treatment of neurological and psychiatric diseases.

Poster sessions

Invited lecturers from all over the world gave 76 lectures, followed by vivid discussions. Special attention was also given to the poster session with numerous posters from neurology and from psychiatry and two best posters from each discipline got the prize given by the City of Graz.

International Neuropsychiatric Pula Congress, organized continuously for the past 54 years, is one of the congresses with the longest tradition in the world in the field of neurology, psychiatry and neuropsychiatry. With its multidisciplinary approach, covering many interesting topics in psychiatry, neurology, and in other related fields of medicine, it is still promoting the fundamental idea of long-established “Pula School of Science and Humanism.”

Council of Delegates 2014

Report to WFN Members

By Raad Shakir, President, WFN

The WFN holds an annual general meeting. As a U.K. registered charity, it is legally required to be accountable to its membership and report its activities and finances on an annual basis.

The Council of Delegates is the highest authority of the WFN. It holds the elected officers and trustees to account and has the full power over all matters related to the activities of the WFN as stated in the WFN Memorandum and Articles of Association. These can be found on the WFN website.

The 2014 Council of Delegates (COD) was held on Sept. 11, 2014, during the joint ACTRIMS/ECTRIMS meeting in Boston, Massachusetts. A total of 34 out of 116 delegates, including those with proxies, were eligible to vote. (See Figure 1 on page 15)

This was my first COD as WFN president, and I thanked the delegates for their trust in electing me as well as thanked my predecessor Vladimir Hachinski for his role in developing the WFN during his term of office. I will do my best to move the organization forward.

The continued collaboration with peer organizations through the World Brain Alliance will be further cemented to ensure that it will prosper. The creation of the Regional Directors Liaison Committee under the chairmanship of Tim Pedley, WFN North America regional director, was reported to council. This committee is independent from WFN officers and is charged with implementing the principle of global involvement through regional empowerment.

Figure 1. Delegates voting on business at the Council of Delegates.

The COD approved several items presented by the trustees. Changes to the WFN Memorandum and Articles of Association were presented. This is an important amendment, which has been recommended by WFN reviewers and endorsed by successive Constitution and Bylaws Committees. The WFN trustees, following legal advice from Hunters, WFN lawyers, approved this change. This specifically separates the post of secretary-treasurer general into two, one of secretary general and the other of treasurer. The reasoning and background was presented to Council. Prof. Alastair Compston (UK) previous chairman of the Constitution and Bylaws Committee further explained the background. The amendment was accepted by unanimous vote. This means that there shall be two posts for COD to elect in Santiago 2015; that of treasurer and another trustee to replace the vacated post of Wolfgang Grisold following his election as secretary-treasurer general.

The Nominating Committee presented the COD with four candidates for the post of trustee. The vacancy was created by the end of the second term of Prof. Gustavo Roman. Prof. Roman has served the WFN for many years and will continue to do so as the chairman of the Latin America Initiative. He served with three WFN presidents; his wisdom and considered advice were invaluable.

The four candidates were Jose Biller (U.S.), Riadh Gouider (Tunisia), Man Mohan Mehndiratta (India) and Serefnur Ozturk (Turkey). Following a second ballot, Prof. Gouider was duly elected as WFN trustee. (See Figure 2.) The officers and trustees welcome Riadh to the team. His experience in the WFN goes back many years and his current position as president of the Pan African Association of Neurosciences Societies would be most useful to the WFN. The WFN is most indebted to Prof. Eduard Auff (Austria), president of WCN 2013 Vienna for supervising the election process.

Figure 2. Prof. Riadh Gouider being elected WFN trustee.

Prof. William Carroll, WFN first vice president, who chairs the WFN Congress Committee and the Specialty Network, spoke at the meeting. He informed the council of the current status of the preparations for the forthcoming congresses in Santiago, Chile, Oct. 30-Nov. 4, 2015, and Kyoto, Japan, Nov. 14-19, 2017. The preparations for Chile are well on target and the submission of abstracts is open. As with all World Congresses, there are a substantial number of travelling fellowships to encourage young neurologists to attend. Prof. Carroll detailed the current status of the close relationship with specialty neurology organizations in partnered educational endeavors and members of the World Brain Alliance in matters of global advocacy; both of which are highly valued by the WFN. The existing disparity between the six WFN regions was emphasized. The trustees are keen to see the growth of stable and independent functioning regional organizations through the coordinated endeavors of the regional directors and initiative chairs.

Prof. Wolfgang Grisold, secretary-treasurer general, presented the WFN financial status. The audited accounts were already sent to all delegates. The WFN is in good financial standing. The WFN is a lean organization run efficiently by two full-time and three part-time staff. The cost of the central office in London and elsewhere is relatively small. The total assets of the WFN at the end of 2013 amounted to £ 3,155,812. The rise in assets in spite of increased spending is mainly due to the excellent profit made by the Vienna WCN. We have to give our gratitude to the Austrian Society of Neurology and the now amalgamated European Federation of Neurological Societies for their efforts and close collaboration. The excellent collaboration will continue with the European Academy of Neurology.

A decision of the WFN trustees was made to allocate 30 percent of the annual budget to grants. The grants for 2013 were already dispersed and those for 2014 were decided and have started to be awarded. The WFN is most grateful to grant reviewers and to members of the World Brain Alliance and Specialty Network for their support and agreement to be partners in financing grants.

Prof. Grisold detailed the success of the World Brain Day, which was held on July 22, 2014. All member societies that participated were duly thanked. The day will be expanded in 2015, and more activities are planned. The WFN publications and website report were detailed and activities on social media were brought to the attention of the council, these continue to grow and expand.

Prof. Grisold outlined the activities of the education committee chaired by Steven Lewis (U.S.) announcing the departmental visiting programs, which successfully started in Turkey, and have now been agreed to start in Austria. The start of the Rabat training program was mentioned, and Prof. Gallo Diop detailed this in his Africa initiative report. Negotiations are under way to establish further WFN accredited training centers.

Prof. Diop, WFN trustee, chair of the Africa Initiative, gave an account of the status of neurology across Africa. Although the situation is still dire in many countries, there is clear increase in neurological services and manpower. This is most welcome and plans to expand the role of the WFN on its own and in partnership with others including EAN, IBRO, IPMDS and AAN were detailed. The WFN is committed to the Africa initiative, which receives financial support through grants, and the reserved fund created following WCN Marrakesh.

Prof. Diop pointed out the start of training African neurologists in Africa with the commencement of training in September 2014, in the first WFN accredited training center in Rabat, Morocco. The WFN is most indebted to the Moroccan Neurological Society and the Moroccan Neurology Foundation for their continuous and indefatigable support for all WFN activities and in particular their commitment to training African neurologists in Africa.

Prof. Roman informed the council of the final stages of the formation of the Pan American Federation of Neurological Societies (PAFNS) to represent Neurology in Latin America. The WFN has designated grants for three developing regions: Asia, Africa and Latin America. This newly formed federation should unite the Latin American neurological world by the time the 22nd WCN is held in Chile.

Prof. Ryuji Kaji (Japan), chair of the Asia Initiative could not be in Boston. I pointed out the huge success of the Asian Oceanian Association of Neurologists. The association is now mature and active. First Vice President William Carroll and I had the pleasure of attending the Asian Oceanian Congress of Neurology in Macau in March 2014. The organization is moving ahead with its activities and is participating in the organization of the 23rd WCN Kyoto.

The COD official business is crucial and its decisions are legally binding to the WFN, but perhaps as importantly, is the interaction and relationships of delegates to renew friendships, start new ones, exchange ideas and news of the past year. There is no replacement for face-to-face meetings. The annual council of delegates meeting is that and much more. The next COD meeting will be held Oct. 31, 2015, in Santiago, Chile.

WFN Election 2014: Recommendations for Nominating Committee

The Nominating Committee of the World Federation of Neurology having invited nominations for one elected trustee post falling vacant with effect, from the 2014 Annual General Meeting (Council of Delegates) on Sept. 11, 2014, recommends the following candidates to the membership:

Prof. José Biller (U.S.)
Prof. Riadh Gouider (Tunisia)
Prof. Dr. Serefnur Ozturk (Turkey)
It is open to anyone to make additional nominations by:
- Obtaining the supporting signatures of five or more authorized delegates
- Submitting the name(s) of the individual(s) in question to the Secretary-Treasurer General, c/o the London Secretariat office, to arrive at least 30 days prior to the date of the Council of Delegates meeting.

A Centenary Tribute to Silas Weir Mitchell

IN MEMORIAM

David G. Kline, MD, FAANS, FACS

By David G. Kline MD FAANS, FACS

This year, we celebrate the 100th anniversary of the death of an extraordinary individual Silas Weir Mitchell (SWM), 1829-1914¹. He was not only a celebrated neurologist, but also a classic experimental physiologist, a critic of insane asylums as well as an innovative therapist for neuroasthenia or what was known in those days as the “vapors.” He authored many poems and works of fiction where his descriptions of characters with mental disorders were both accurate and unique^2,5,6. (See Figure 1.)

SWM was born and raised in Philadelphia, a son of Dr. John Kersley Mitchell, a graduate of the University of Pennsylvania Medical School and member of the Jefferson faculty, and the third of nine children borne by Sarah Matilda Henry. He was raised in a family setting stressing versatility in reading literature as well as writing and reciting poetry⁸. He went to Penn as an undergraduate, but was a desultory student, preferring reading and billiards to his studies. He left after several years to help his family because his father had fallen ill. Even though Mitchell felt SWM had little aptitude for medicine, he entered Jefferson Medical School in 1848, graduating in 1850 at the age of 21.

Figure 1. Frontispiece of A.R. Burr’s book, “Weir Mitchell: His Life and Letters,” including portrait of Silas Weir Mitchell, published in 1929 by Duffield and Company, New York.

SWM and his sister, Elizabeth, went to Europe where he spent time with Claude Bernard, the Parisian physiologist who taught him “if you need an answer, do an experiment.” He applied for an internship at Pennsylvania Hospital, but was turned down for political reasons connected with his father. He joined his father’s practice and then assumed it when he retired in 1855.

During that period, he became an experimental physiologist studying among other topics, the effect of rattlesnake venom on various animals, the blood crystals of sturgeons, the generation of uric acid and the mental effects on himself of ingestion of mescal buttons^10,11,12.

When the Civil War began, SWM wanted to avoid conscription so he could keep his practice alive and help his mother with the large Mitchell family since his father died in 1858. A friend who became Surgeon General for the Union Army, William Hammond, made him a contract surgeon at Turner Lane Hospital on South Street in Philadelphia⁴. There, along with Keen and Morehouse, he cared for a large number of war wounds, many involving nerves and leading to amputation. SWM and his colleagues went to battlefields such as Gettysburg and brought back the wounded in wagons. He sold his contract for $400 after several years so that he could return to civilian life, but this Civil War experience led to the classic text, “Gunshot Wounds and Other Injuries of Nerves” (1864) and in 1872, “Injuries to Nerves and their Consequences.” Of interest, SWM’s fictional account of a union officer and physician titled, “The Strange Case of George Dedlow,” was published under a nom de plume in the Atlantic Monthly and became immensely popular¹⁴. His accounts of causalgia and phantom limb pain or disorder attracted the public’s imagination and led to a second rendering published by Lippincott’s magazine⁹. (See Figure 2.)

Figure 2. Text extracted from Silas Weir Mitchell’s publications about phantom limb pain (syndrome).

SWM published many scientific papers, his neurologic practice thrived and he found time to write “Wear and Tear: Hints for the Overworked” (1871). It sold out in 10 days, and four other editions were published. He also published “Fat and Blood” (1877). Eight editions were published. He married Mary Middleton Elwyn in 1858, and she bore two sons. Tragically, they both died of diphtheria in 1862. He remarried Mary Caldwalder from a socially prominent Philadelphia family in 1874. That same year, he lost his sister, to whom he was very close, also to diphtheria. Yet another family tragedy included the loss of a daughter from his second marriage whom he doted on. She was 22 years old. This prompted his publication of a poem, “Ode to a Lycian Tomb,” which again for that period became quite popular¹³.

As was the custom at that time, prominent Philadelphians traveled north for the summer months, and SWM’s family was no exception. Initially, they summered in Newport, Rhode Island, and subsequently in Maine and occasionally Canada. SWM was an avid reader, and on these lengthy sojourns, he soon ran out of fiction to read so he began to write novels himself. His first book, “In War Time” (1884) was initially published in 12 issues of the Atlantic Monthly. Beginning in his 50s, he began to write and publish 13 novels, mainly about society at that time in Philadelphia and the effect of conflicts such as the Civil War and the American and French Revolutions on civilian life². (See Figure 3.)

SWM had developed a keen interest in mental disorders, and he used that in a very descriptive way with his fictional characters. His literary detractors even extolled that trait, but faulted his lack of substantial plots or at least ones that moved along. He did tend to emphasize the genteel in society instead of the common man. He ignored or failed to develop any fictional, sexual encounters or connotations^5,8. Despite these criticisms about plots, one can find distinct exceptions among these novels. Thus, substantial plots at least for this reader can be found in “The Adventures of Francois — a French Revolution Juggler and Thief” (1897) or “Hugh Wynne. Free Quaker: Sometime Brevet Lieutenant — Colonel on the Staff of His Excellency General Washington” (1896) and “Constance Trescott” (1905). “Constance Trescott” portrays a vengeful widow who moves to Missouri from New England shortly after the Civil War.

Figure 3. The frontispiece of J.P. Lovering’s “S. Weir Mitchell,” published in 1929 by Twayne Company, New York.

Despite moving into the top social circles in Philadelphia, SWM treasured his medical and fictional authorship more than social pleasures. Perhaps in part because of his social status though as well as his popularity as a physician, he was made a trustee at Penn in 1875 and helped found a Department of Mental Diseases, mentoring two subsequent chairs — Mills and Burr⁷. He recruited William Osler from Canada to the chair of the Medicine Department and even helped his son obtain an academic appointment, something he had always cherished for himself but never gained at least as a chair at either Penn or Jefferson.

Mitchell became president of the Association of American Physicians (1887), president of the American Neurological Association (1908-1909) and was given honorary degrees at Harvard, Edinburgh, Princeton and Toronto before dying of influenza in January 1914¹. He was buried in the Philadelphia area in the Woodland Cemetery¹⁶.

Along with Benjamin Rush, SWM is considered the father of neurology in America⁴. Some described him as pompous and dictatorial, and as he grew older, somewhat irascible but “as a young man he took first place among the physiologists of the day, in middle age first among physicians, and as an older man, he was among the novelists of his country¹⁴.” (See Figure 4.)

This paper was presented June 9, 2014, to the 86th dinner meeting of the Philadelphia Neurological Society founded 134 years ago by Silas Weir Mitchell. •

References

Figure 4. Mitchell’s final home with Mary Caldwalder, 1524 Walnut Street, Philadelphia. On this home was mounted a brass plaque commemorating his many lifetime accomplishments.

1. Bailey P: A biographical memoir of Silas Weir Mitchell (1829-1914), National Academy of Sciences Publication pp 332-53, 1958

2. Burr AR: “Silas Weir Mitchell: His Life and Letters,” Duffield Co, NY, NY, 1929

3. Cervetti N: “Silas Weir Mitchell (1829-1914): Philadelphia’s Literary Physician,” Pennsylvania State University Press, 2012

4. Drabelle D: The Case of Silas Weir Mitchell, Penn Gazette, pp 40-3, Nov-Dec 2012

5. Finger S, Hustwit MP: Five Early Accounts of Phantom Limb in Context: Pare,Descartes, Lemos, Bell, and Mitchell, Neurosurgery 52:675-86,2003

6. Lau FH, Chung KC: Silas Weir Mitchell MD: The Physician Who Discovered Causalgia, J. Hand Surg (Am) 29(2): 181-87, 2004

7. Ledger M: Benjamin Rush and 20 Years of Penn Psychiatry, Penn Medicine, pp22-33, Fall 2012

8. Lovering JP: “Silas Weir Mitchell: His Life and Letters,” Twayne Pub. NY, 1929

9. Miller E: Truth, Stranger Than Fiction, Silas Weir Mitchell and Phantom Limbs, Pharos Autumn, 2011

10. Mitchell SW: “Researches Upon the Venom of the Rattlesnake: With an Investigation of the Anatomy and Physiology of the Organs Concerned,” Smithsonian Institution, Washington, DC

11. Mitchell SW: Remarks on the Effects of Anhelonium Levinii (The Mescal Button) BMJ 21:1625-29,1875

12. Mitchell SW: On a Rare Vasomotor Neurosis of the Extremities and on Maladies With Which it May Be Confounded, Am J Med Sci 76:17-36, 1878

13. Mitchell SW: “Ode on a Lycian Tomb,” The Century Magazine, LXXV (1), 85-88, 1907

14. Nome de Plume (SWM): The Strange Case of George Dedlow, Atlantic Monthly 18(105):1-11, 1866

15. Rein D: “Silas Weir Mitchell as a Psychiatric Novelist,” International University Press Inc, NY,NY 1967

16. Toodayan N: “Silas Weir Mitchell (1829-1914): The Man and his Malady,” Love of Books, Brisbane, Australia, 2014

Kline is the Emeritus Chair and Boyd Professor, Louisiana State University Medical Center, New Orleans, Louisiana.

Arthur Simons and Tonic Neck Reflexes in Hemiplegic Persons

By Bernd Holdorff

Bernd Holdorff

Tonic neck reflexes in animals and men were described by Magnus and de Kleyn in 1912.

It became his most important publication and remained unsurpassed for the next years. A film from the years 1916-1919, with Arthur Simons as examiner, shows these nearly forgotten phenomena. (See Figure 1.) He already emphasized their everyday significance in 1920, long before the rules of antispastic positions were defined by Bobath.

After several clinical activities, mostly in unpaid positions, and subsequently as the leading assistant in the outpatient service (Poliklinik) of Hermann Oppenheim in the years before WWI, Simons (1877-1942) had to do military service as a physician from 1914 to 1918. He succeeded in assembling neurological case reports and publications to fulfill the academic requirements for the “Privatdozent” or “Habilitation Act” in 1921 and for a professorship (a.o.= extraordinary professor) in 1923.

After Oppenheim’s death in 1919, he worked in an outpatient practice and as consultant neurologist in Berlin hospitals until 1933, where he was continuously deprived by the Nazi regime, because of his Jewish origin. Requests for immigration to England failed and meanwhile his private practice lost more and more patients. In 1938, he lost his medical license and had to accept the profession of “Krankenbehandler.” Alimony for his divorced wife forced him to sell more and more of his art collections as well as his household. In September 1942, he did not return from a citation to the Gestapo, and after intermediate detention in October 1942, he was taken to Reval (the present Tallinn, Estonia) where he was murdered.

Figure 1. Still with Arthur Simons as examiner. Upper part: left hemiplegia after brainshot wound, metal rod loosely in the right hand, paretic leg slightly bent and passively held by Simons Lower part: head rotated to right, hemiplegic associated reactions (Mitbewegungen) on the left side elicited by voluntarily right forced grasp: abduction of upper arm, elbow flexion, elevation of the left hand and fist clench, flexion of hip and knee, adduction of the thigh, dorsiflexion of the foot and the toes as well as inversion. (Not shown here: head rotation to the left in combination with voluntarily forced grasp of the right hand resulting in slight extension, adduction and pronation of the forearm, hand extension and clench of the fingers, as well as left leg in strong extension, inward rotation, foot flexion and toe extension.)

In 1912, Magnus and de Kleyn, in the Netherlands, studied in detail the labyrinthine and the postural reflexes in animals as well as humans. Following Rudolf Magnus, tonic neck reflexes are the consequence of a change of the position of the head in relation to the trunk, which causes an increase or decrease of tonus of ipsilateral muscles (asymmetrical tonic neck reflexes), while dorsi- and retro-flexion of the head results in bilateral change of tonus (symmetrical tonic neck reflexes).

As a result of Magnus’ animal experiments, the anatomical basis of tonic neck reflexes could be located in the upper cervical spine. They are decreased after extirpation of the first cervical root and completely disappear after cutting of the second cervical root. Tonic neck reflexes are elicited in the newborn during the first weeks and reappear only in cerebral disease.

After the coincidental observation in his first patient at the military hospital, Simons wrote: “In the autumn 1916, I examined a hemiplegic patient in the field two months after an injury by gunshot in the head”¹. Simons undertook a thorough series of investigations, and at the end of the war, he had observed 31 hemiplegics. By 1919, he had seen 248 cases, of which 25 percent presented tonic neck reflexes with hemiplegic “Mitbewegungen” (synkinesias). He produced a film (Filmarchiv, Bundesarchiv, Berlin) that shows 11 cases from the years 1916-1919, mostly with war brain injuries.

The asymmetric neck reflexes with flexion or extension on the hemiplegic side, called “Mitbewegungen” (synkinesias), identical to Francis Walshe’s “associated reactions” (1923)², are induced (increased or varied) by neck rotation with simultaneous co-contraction of the non-affected extremities, e.g. by closure of the fist. They are restricted to the paralyzed side. The stills shown in Figure 1 are taken from the film.

Investigations by Simons and Walshe were done exclusively in the adult and awake hemiplegic, show that tonic neck reflexes are bound to a lesion of the pyramidal tract and should be understood as a form of decerebrate rigidity. They belong to Magnus’ postural reflexes, or “Stellreflexe,” the English term of which is “position” or “righting reflexes” and are situated in the brain stem.

Walshe was fair enough to acknowledge Simons’ milestone discovery in his final addendum. In 1925, the Hamburg neurologist Heinrich Pette stated in his own investigation on tonic neck reflexes that “up to now, they remain unique in this manner of large scale work.” The reproduction of Simons’ film stills by Magnus in his 1924 Körperstellung³, by Rademaker in his 1931 Das Stehen, as well as by Stenvers in his chapter in Bumke’s & Foerster’s Handbook of Neurology (Vol. 5, 1936) bestowed them a historical value.

After that period, the couple Berta and Karl Bobath, in their English exile, used the neck reflexes in physiotherapy and position of hemiplegics in order to decrease their spastic tonus, unfortunately relying only on Walshe’s work and not on Simons’ efforts.

References

1. Simons A (1923) Kopfhaltung and Muskeltonus. Ges.Z. Neurol.Psychiatr. 80: 499-549.

2. Walshe FMR (1923) On certain or postural reflexes in hemiplegia, with special reference to the so-called “associated movements.” Brain 46: 1-37.

3. Holdorff B (2012): Arthur Simons (1877-1942) über tonische Halsreflexe beim Hemiplegiker aus den Jahren 1916-1919. Nervenarxt 83: 514-520.

Holdorff is the former head of the neurologic department Schlossparkklinik, Berlin. Koehler is the editor of this history column. He is neurologist at Atrium Medical Centre, Heerlen, The Netherlands.

Do’s and Don’t’s in Neurology

EAYNT SPECIAL SESSIONS AT EFNS-ENS JOINT CONGRESS

Dr. Laszlo Sztriha discussed mobility across countries.

By Monica Moarcas, Antonella Macerollo, Johann Sellner and Walter Struhal

During neurology training, there are crossroads where the best decision is based on advice from more experienced colleagues and professors. The choice to dedicate to research or pursue the clinical path is among the first steps, and visiting departments of other sites may aid in building a career plan.

The European Association of Young Neurologists and Trainees (EAYNT) is a non-profit independent organization aimed at linking young neurologists across Europe in respect to educational and exchange of experience opportunities. In the last 14 years, it has brought together young neurologists at its Special Sessions organized at EFNS meetings where experienced speakers have discussed aspects of training and planning professional development.

During the EAYNT Special Session at EFNS-ENS Joint Congress Istanbul 2014, Prof. Jose Ferro, Prof. Walter Paulus and Dr. Laszlo Sztriha offered lectures on the “Do’s and Don’t’s in Neurology Training” covering the complementary perspectives of research and clinical work of young neurologists.

Sztriha from King’s College Hospital, London, talked about mobility across Europe during training in neurology as seen by a young neurologist. He showed that the goals of visiting a hospital in a different country include improving clinical expertise, research opportunities and possibilities to apply the new knowledge in home department. He also recommended identifying the most suitable place to visit — based on language compatibility — by looking for opportunities published on department homepages or journals or by meeting staff members at conferences or through special mobility programs that offer the opportunity to visit departments. He also discussed funding for EFNS and ENS programs, fellowship from home departments or from host institution. Sztriha also offered valuable practical advice regarding opportunities for experience exchanges for young neurologists.

Prof. Jose Ferro identified research challenges.

Prof. Jose Ferro from Santa Maria Hospital, Lisbon, Portugal, talked about the do’s and don’t’s of research. Ferro presented the steps a young researcher needs to take to build a successful career based on skills and knowledge and focused on the mission, which is determined by goals and values. He emphasized personal and interpersonal competencies of a researcher, as well as the importance of self-analysis. He also discussed the essential role of a mentor. He shared aspects from his own professional path as a researcher and presented the importance of working in foreign departments. The importance of being constant in the research topic and issues regarding authorship of papers were two important points of this talk. Ferro concluded by highlighting that determination and hard work are key characteristics of researchers who should never forget their missions.

Prof. Walter Paulus from University Medical Center Goettingen, Germany, focused on do’s and don’t’s of clinicians. Paulus presented data regarding how satisfied trainees are with their training process through a German survey. Next, he showed the current work situation of a clinician, which is between growing clinical demands, the competition for research, more administrative issues to handle that are partially compensated by stability of job and a less stressful environment after work. The lecture continued with focus on attributes a successful clinician should have, including empathy, perseverance, ambition, structured thinking, curiosity and good clinical skills. On the contrary, he discussed characteristics that a clinician should not have: a lack of interest, insufficient skills, inappropriate attitude toward colleagues and forcing the symptoms into a diagnosis.

Prof. Walter Paulus discussed clinician training.

Paulus highlighted the importance of minimizing the clinician’s own mental distress in order to ensure patient safety, and a good working atmosphere is a collective effort along with the information exchange and acquisition.

He also talked about problems he observes in residents, including poor clinical judgment, patient management, absenteeism, inappropriate interaction and management through better supervision. He highlighted the importance of mentoring residents throughout their training.

Neurology training represents a sequential process that needs personal effort to improve knowledge and skills, determination, understanding of the aims and goals and of methods to achieve them. In addition, there needs to be the touch of personality of a true mentor who not only teaches and supervises, but also serves as a model.

The three lectures gave young neurologists the opportunity to have a better understanding of aspects of training both in clinical field and research, in home departments and abroad.

Moarcas is with the Department of Neurology, Emergency University County Hospital Brasov, Romania.

Editor’s Update and Selected Articles From JNS

By John D. England, MD

John D. England, MD

Readers of the Journal of the Neurological Sciences will soon notice a few changes between the covers. The Editorial Board and I are gradually changing the way in which case reports are handled and published. JNS continues to receive a large number of manuscripts submitted from around the world.

Because of publication limitations, we can accept only a minority of these manuscripts for publication. Although case reports are usually considered reports of “anecdotal” observations, most clinical neurologists find them educational and interesting. Rather than reject all of these case reports, we have decided to publish many of them as “Letters to the Editor.” In this way, we can accommodate them within JNS.

The journal also will be featuring more “editorials” to highlight and enhance important original articles, which will be published simultaneously. These will usually be solicited by invitation from one of the associate editors or me. However, if you are asked to review a manuscript for JNS and believe that an accompanying editorial would be useful, please provide this as a recommendation in your review.

In our ongoing attempt to enhance accessibility of JNS articles to members of the World Federation of Neurology (WFN), we have selected two “free–access” articles, which are profiled in this issue of World Neurology.

In this issue, we feature two paired articles:

1) In the first article, Dennis Paul and colleagues provide new observations about the ubiquitous and important Na⁺-K⁺ ATPase pump. This research team previously documented that inflammation results in an up-regulation of sodium channels (especially Nav1.7) in dorsal root ganglia (DRG). Using the same experimental paradigm, they have now demonstrated that there is a simultaneous up-regulation of the Na⁺-K⁺ ATPase pump. The researchers had hypothesized that this would occur since without an up-regulation of the Na⁺-K⁺ ATPase to pump Na⁺ out of the cells, an increase in Na⁺influx would lead to an osmotic influx of water. Consequently, the DRG cells would swell and burst. As proof of the protective mechanism provided by an increase in the Na⁺-K⁺ ATPase pump, the authors blocked the activity of the pump with ouabain. This pharmacologic blockade resulted in the swelling and death of the DRG cells which had an inflammation-induced increase in Na⁺ channels. These observations have important implications for the pathophysiology of inflammatory conditions and concomitant neuropathic pain. They may have broader importance for the pathophysiology of other diseases such as diabetes mellitus, which is known to interfere with Na⁺-K⁺ ATPase pump expression and function. Specifically, interference with the function or blockade of the Na⁺-K⁺ ATPase pump might cause premature cell death in susceptible cells. Paul D, Soignier RD, Minor L, Tau H, Singu-Mize E, Gould HJ. Regulation and pharmacological blockade of sodium-potassium ATPase: A novel pathway to neuropathy. J Neurol Sci 2014;340:139-143.

2) In the second article, Craig Stevens provides a thoughtful and comprehensive editorial about the biological importance of the Na⁺-K⁺ ATPase pump. This paper serves as a brief primer on the importance of the Na⁺-K⁺ ATPase pump for maintaining the resting membrane potential and volume in all cells. He also highlights the growing evidence that Na⁺-K⁺ ATPase dysfunction may be involved in several neurological diseases in addition to peripheral neuropathy. Stevens CW. New pathways for an old molecule: The role of the Na+-K+ ATPase pump in peripheral neuropathy. J Neurol Sci 2014;340:3-4.

England is editor-in-chief of the Journal of the Neurological Sciences.

European Academy of Neurology Sixth Regional Teaching Course in Sub-Saharan Africa

Wolfgang Grisold

By Wolfgang Grisold

The Sixth Regional Teaching Course (RTC) of the EAN took place in June in Lusaka, Zambia. There were 124 participants from 20 Sub-Saharan countries in attendance.

The course, which was organized by the EAN, was supported by a consortium of European and international scientific societies also by the WFN.

American Academy of Neurology (AAN)
Epilepsy Association of Zambia
International Brain Research Organization (IBRO)
International Parkinson and Movement Disorder Society (MDS)
Pan African Association of Neuroscience Societies (PAANS)
University of Zambia
World Federation of Neurology (WFN)
World Stroke Organization (WSO)
Zambian Ministry of Health

An unrestricted educational grant was obtained from the Lundbeck International Neuroscience Foundation. The course faculty of international educators included: Erich Schmutzhard and Wolfgang Grisold (Austria); Riadh Gouider (Tunisia); William Howlett (Tanzania); Jean-Michel Vallat (France); Anthony Zimba and Masharip Atadzhanov (Zambia); Raj Kalaria, Peter Sandercock and Tim Steiner (UK); Amadou Gallo Diop (Senegal); Angelo Antonini (Italy); James Bower (U.S.); Osheik Seidi (Sudan); and Mehila Zebeginus (Ethiopia).

This three-day RTC covered infection and nervous system disorders, including stroke and movement disorders and disorders of the peripheral nervous system.

The topics were relevant and up to date. In addition to the teaching aspects, all of the visiting professors emphasized how the latest developments and ideas involved in the diseases under discussion could be implemented.

The program was selected by participants from the previous year, based on a poll. The lectures were presented with PowerPoints. Some sessions were supported by video demonstrations. All presentations were followed by discussions, and there was time for questions after each main lecture session. At the end of each block, a question-and-answer session was allowed, which was highly interactive. The faculty joined in guessing the answers and in the discussions, and several academic points of view were aired.

In the afternoon teaching sessions, a pair of lecturers demonstrated cases and encouraged participants to be actively involved in breakout sessions. These cases were either based on video demonstrations, images or classic narrative case descriptions. Participants were asked for their opinions. In some instances, an emphasis on a structural approach was studiously followed. This proved to be interesting, and the teaching sessions were highly informative. In addition, the participants were exposed to the different teaching styles of the faculty depending on the school of teaching (U.K., France, Italy, U.S.) or personal styles.

Both the case discussions as well as the general discussions revealed positive and critical aspects: It seems that young neurologists are exposed to a huge quantity of diseases and patient needs in their countries, but they have limited resources in so many ways. But their knowledge and interest is great, and this is what makes this course exciting.

Also, as a critical remark, their sometimes limited knowledge of English can be noted, and there is often some hesitancy to express their opinions in discussions with the teaching professors. Notably, however, the interaction between residents and faculty improved considerably during the course.

Some selected lectures were given by young neurologists, which were technically well prepared, and discussed with the audience.

A special experience was the session on “How to Write Paper.” Three experienced teachers — Dr. Gallo (Senegal), Dr. Kalaria (UK) and Dr. Bowers (US) — each gave a presentation and discussed many aspects, from the selection of a topic, the preparation, technical aspects of the manuscript and how to deal with journal editors and reviewers.

Social Interaction

There was an official reception on Thursday, which was attended by the First Lady of the State Christine Kaseba-Sata, Goodwill Ambassador to WHO, who gave the meeting an official standing. This cannot be estimated highly enough in a country with 40 million inhabitants and only one neurologist. This meeting also was covered by local news and TV, which will likely increase the awareness of neurology in Zambia.

Lunch and coffee breaks were used eagerly for information and exchange.

Local Society of Neurology and Psychiatry

The local neurology department is based on the work of Anthony Zimba and Masharip Atadzhanov. The department in Lusaka contains a WFN-sponsored neurological institute, which now has established EEG and EMG. The university has one MRI and laboratory investigation also offering PCR techniques for neuro-infectious diseases.

Impression

This sixth course seems like a big effort to make, demanding a lot of resources for a small group of attendees in relation to the large number of countries without neurology services. However, all of the attendees are devotedly involved in neurology and are important proponents for neurology.

Furthermore, this course can be considered the ignition or spark for newly developing neurological societies, units and neurologists. The fuel is the knowledge of the importance of neurology and education, which will drive the development in individual countries. An example is Ethiopia, which has profited from the first TC and which has since produced a training program.

WFN’s role is to keep up this spirit of teaching, and encourage and partner with other organizations to improve this momentum of teaching, learning and creating neurology in Africa.

To meet this continuing need, the EAN-led planning group met in Lusaka to plan the next course. The participants were asked to list three topics of interest they would like to see addressed in a future RTC. From the compilation of the suggested topics, two that had the highest number of requests were identified for the 2015 RTC. The seventh RTC will be held in October 2014 in Khartoum, Sudan, and will be hosted by Prof. Osheik Seidi and the University of Khartoum. The themes of the conference will be neuro-pediatrics and stroke.

Grisold is with the Department of Neurology, Kaiser Franz Josef Hospital, Vienna, Austria.