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PRESIDENTIAL ADDRESS
STANLEY FAHN, MD
A HISTORICAL PERSPECTIVE ON MOVEMENT DISORDERS

When AAN President Stanley Fahn, MD, offers the Presidential Address this year on “What's New in Parkinson Disease,” he will approach the podium bearing the weight of history. The H. Houston Merritt Professor of Neurology at Columbia University and Scientific Director of the Parkinson's Disease Foundation can well remember when the concept of Parkinson disease as a movement disorder was altogether new.

In fact, when Dr. Fahn graduated from medical school at the University of California-San Francisco, in 1958, the term – movement disorders – was not used.

While neurologists at the time knew that Parkinson disease was just one of several degenerative disorders involving the basal ganglia, these disorders weren't yet grouped together or studied as a whole, he explained.

NAMING MOVEMENT DISORDERS

But all that changed in 1968, when Lewis P. Rowland, MD, recruited him from Columbia University to the University of Pennsylvania to launch a Parkinson disease clinic, exploring the then-fledgling understanding of levodopa as a treatment for the disease.

“I didn't want it to be simply a Parkinson clinic. I wanted it to be broader, to cover all the various diseases of the basal ganglia,” Dr. Fahn recalled. “We needed a more all-encompassing name, and so we sat around discussing the concept. I think Dr. Rowland came up with the term ‘movement disorders.’ So I started the clinic, which we called the Movement Disorders Clinic.”

Today, every young neurologist studies the category of brain diseases that Drs. Fahn and Rowland gave a name and a research identity on that day in 1968. Indeed, many of them attended the hugely popular interactive course at the Annual Meeting of the AAN, “Unusual Movement Disorders,” which Dr. Fahn launched with the late David Marsden, MD, more than 20 years ago. But if dozens of young scientists can trace their path into movement disorders via a map charted in part by Dr. Fahn, what first set Dr. Fahn on his path?

PASSION FOR NEUROANATOMY

Like many neurologists, Stanley Fahn was wooed into the field when, as a first-year medical student, he fell in love with neuroanatomy during a special course on the subject. “I loved the intricacies of the brain, mapping its pathways and figuring out where lesions would be located. I was fascinated by how the nervous system worked in general,” he recalled.

“It seemed to come easily to me. I've found that most neurologists, at least the ones I've talked to, fell in love with neurology through neuroanatomy. I guess it is a certain mindset that happens to fit very well with the way the brain is organized.”

ONWARD TO NEUROCHEMISTRY

But during the first year of his neurology residency, Dr. Fahn found himself debating the next step to take: neurology or neurosurgery? Surprisingly, a rotating internship in psychiatry drew him back into neurology. Or perhaps not so surprisingly, considering how much neurology and psychiatry share.

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Dr. Stanley Fahn

“Freud was a neurologist before he was a psychiatrist, after all,” Dr. Fahn said. “I remember I was intrigued with a case of schizophrenia in which some analysts had brought the patient back to infantile days and he relived those experiences in his mind. I just decided that the brain was too powerful an organ to neglect and that we'd better study it more.”

Believing the way to conquer neurodegenerative disease – a particular passion of his – was through brain chemistry, Dr. Fahn headed to the National Institutes of Health after his residency to learn neurochemistry. Then he returned to Columbia, where he'd done his residency, to start his own lab, and made the life-changing decision to attend an international symposium on the pharmacology of the basal ganglia.

“What turned me on completely was to hear Dr. Oleh Hornykiewicz. This was 1965, and in 1960 he had published in a German medical journal his discovery that dopamine levels were reduced in the brains of Parkinson disease patients,” Dr. Fahn recalled. “He presented that and his follow-up studies at the symposium. I decided then and there that I wanted to get involved with the basal ganglia and learn its biochemistry.”

COMBINING ART AND SCIENCE

Dr. Fahn sees his field as a combination of art and science. “It is a more complicated specialty today than it used to be, mainly because of the choice of drugs and what we can do in modifying the symptoms of disease. We have powerful drugs, but they have side effects, and you have to know how to predict them.

“Our new understanding of genetics has given us some ideas on pathogenesis, and that's very exciting,” he said. “But the basic feeling I have about the field of movement disorders – and why I feel so fortunate to be a part of it now – is that it is not only the development and excitement of new treatments and new research. We're still clinicians taking care of patients. We evaluate patients by seeing them and doing neurological exams on them, so we still feel like old-fashioned doctors, but we have modern tools in treating them.”

THE SAME BASICS

Despite contemporary advances, Dr. Fahn said, some things haven't changed much from his early days studying movement disorders.

“We have gene tests, MRIs, CAT, and PET scans; all these tools do help us and we use them. But for the most part we still depend on old-fashioned neurology: taking a history and examining the patient. Sometimes you have to sit with the patient for a long time to see what kind of movements they make. There is nothing like experience to see the different movements. You never see enough; there is always something new coming along.”

“Something new” is exactly what Dr. Fahn's presentation at the symposium will focus on – the last decade's most critical developments in Parkinson disease, from the pathogenetic insights offered by basic science to the sometimes overwhelming new choices in protective drugs now available at the earliest stages of the disease.