Other Early Descriptions

Prior to Parkinson’s description, references to tremor are found in the writings of Hippocrates, Silvius de la Böe (1663, 1680) and Sauvages (1768).  A possible description of Parkinson’s disease in Sanskrit is recorded under the name of Kampavata in the ancient Indian medical text, Basavarajiyam (1400).

Building on Parkinson’s case histories, Jean-Martin Charcot was the primary figure to bring Parkinson’s disease to international attention.  In his teaching at the Salpêtrière hospital in the 1860’s and thereafter, Charcot highlighted the cardinal features of rest tremor, bradykinesia, rigidity, and gait/balance that typify Parkinson’s disease.  He and his students described the full clinical spectrum of the disease, noting two prototypic forms, tremorous and rigid/akinetic.  Additionally, they described arthritic changes, pain, dysautonomia, and mental alterations that occur in the disease’s natural history.  Charcot was the first to suggest the term “Parkinson’s disease”, rejecting the earlier designation of “paralysis agitans”, noting that Parkinson’s disease patients are not markedly weak, nor do they necessarily have tremor. 

Gowers likewise contributed additional seminal observations based on his personal experience with 80 patients in his London practice.  His Manual of Diseases of the Nervous System (1888) emphasized mid-life onset and male predominance. 

The first autobiographical notes of a celebrated Parkinsonian patient are found in the letters of Wilhelm von Humboldt, the German academic reformer, humanist and statesman.  His letters from 1828 until his death in 1835 document resting tremor, micrographia, a sense of internal shaking, coordination difficulties, and the frustration of enduring progressive motor decline.  A statuette of von Humboldt by Friedrich Drake (1834) captured the typical parkinsonian posture years before the more widely known medical statues of Paul Richer.

Early cinematographic documents by Marinescu, Van Gehuchten and later, Putnam and Herz, captured the features of Parkinson’s disease and allowed for frame-by-frame analysis.  The propulsive and retropulsive balance difficulties of untreated Parkinson’s disease are particularly well captured.  Film documents of post-encephalitic parkinsonism serve as contrasts.

Hippocrates (460-377 B.C.)

Sylvius de le Böe (1614-1672), also known as Sylvius after whom the Sylvian fissure was named, was a celebrated physician and professor of medicine in Leyden. He described involuntary movements including rhythmic tremors and intermittent clonic tics.

From Finger S. (1994) Origins of Neuroscience A History of Explorations into Brain Function, Figure 2.9, p. 23.  New York, Oxford University Press.

François Boissier de Sauvages de la Croix (1706-1767)

Courtesy of the National Library of Medicine.

Photo from Goetz, C.G. (1987) Charcot, The Clinician.  New York: Raven Press. Private Collection, courtesy of MDS Member, Christopher G. Goetz, MD, Chicago, IL.

Jean-Martin Charcot identified the cardinal features of Parkinson’s disease and specifically separated bradykinesia from rigidity:

Long before rigidity actually develops, patients have significant difficulty performing ordinary activities:  this problem relates to another cause.  In some of the various patients I showed you, you can easily recognize how difficult it is for them to do things even though rigidity or tremor is not the limiting feature.  Instead, even a cursory exam demonstrates that their problem relates more to slowness in execution of movement rather than to real weakness.  In spite of tremor, a patient is still able to do most things, but he performs them with remarkable slowness.  Between the thought and the action there is a considerable time lapse.  One would think neural activity can only be effected after remarkable effort.    
Charcot, 1869

Figure 7 (page 138) reproduced with permission from (CV) Lectures on the Diseases of the Nervous System, Volume 1, by J.M. Charcot.  Gryphon, Editions, The Classics of Neurology and Neurosurgery Library, 1985.

The writing hand.  Habitual attitude of the hand at a somewhat advanced stage of paralysis agitans.
Digital deformation, simulating that of primative chronic articular rheumatism.
Digital deformation, simulating that of primative chronic articular rheumatism.

Figures 8, 9, 10 (pages 141-142) reproduced with permission from (CV) Lectures on the Diseases of the Nervous System, Volume 1, by J.M. Charcot.  Gryphon, Editions, The Classics of Neurology and Neurosurgery Library, 1985.

Charcot described diverse aspects of clinical evolution of Parkinson’s disease, including pain, dysautonomia and joint deformities. He documented both micrographia and tremor during handwriting. Commenting on Parkinson’s Essay on the Shaking Palsy, Charcot told his students in 1888:

“It is a small pamphlet almost impossible to find. After a frustrating search, I now own a copy thanks to Dr. Windsor, librarian at the University of Manchester. As short as the work is, it contains a number of superb ideas and I would encourage any one of you to embark on a French translation….Read the entire book and it will provide you with the satisfaction and knowledge that one always gleans from a direct clinical description made by an honest and careful observer.”

Charcot recognized the distinctive dysautonomia of  Parkinson’s disease, noting how these patients experienced a sense of hyperthermia even in the drafty, cold wards of the French hospitals:

“In the midst of winter (everyone of my service will substantiate this), you can see the parkinsonian patients with no blankets covering them and with only the lightest clothes on …they feel hot especially around the epigastrium and back, although the face and extremities can also be the focus of their discomfort.  When it occurs, it is often accompanied by such severe sweating that the sheets and pajamas may need changing.  I assure you that regardless of how hot these patients feel or how much they shake, their temperature remains normal.”

Photo from Goetz, C.G., Bonduelle, M., and Gelfand, T. (1995).  Charcot: Constructing Neurology, Figure 5-9, p. 162.  New York:  Oxford University Press.
Private Collection, courtesy of MDS Member, Christopher G. Goetz, MD, Chicago, IL.

Photo from Goetz, C.G. (1987) Charcot, The Clinician.  New York: Raven Press.
Private Collection, courtesy of MDS Member, Christopher G. Goetz, MD, Chicago, IL.

Parkinsonian Women
These figures, drawn by Charcot’s student, Paul Richer capture the deforming posture and progression of untreated Parkinson’s Disease over a decade.  As the director of the medical unit at the Salpêtrière hospital in Paris, Charcot had access to large numbers of patients who lived in the chronic facility.  Because patients were charges of the state, autopsies were regularly performed, although Charcot failed to identify a pathological lesion in  Parkinson’s disease.

Richer Statue
The Charcot neurological service at the Salpêtrière had extensive ancellary divisions including medical art and photography. Charcot engaged Paul Richer who also was on the faculty at the Paris Ecole des Beaux Artes to draw and create statues of archetypical disorders. This statue of an elderly woman with Parkinson’s disease is a limited edition plaster mold from the original form.

Private Collection, courtesy of MDS Member, Christopher G. Goetz, MD, Chicago, IL.

Statuette of Wilhelm von Humboldt
Created by Friedrich Drake in 1834 this statuette shows the hunched posture and flexed arm typical of Parkinson’s disease. 

Private Collection, courtesy of MDS Member, Werner Poewe, Innsbruck, Austria.

William Gowers was among the great British physicians of the nineteenth century brought the National Hospital Queen Square into international prominence. More gifted in written descriptions than visual renditions, Gowers offered one of the most memorable descriptions of parkinsonian tremor:

“The movement of the fingers at the metacarpal-phalyngeal joints is similar to that by which Orientals beat their small drums.”

Private Collection, courtesy of MDS Member, Christopher G. Goetz, MD, Chicago, IL.


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