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Is "Parkinson's Disease" One Disease?

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Is J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.52.Suppl.18 on 1 June 1989. Downloaded from Journal ofNeurology, Neurosurgery, and Psychiatry. Special Supplement 1989:18-21 Is "Parkinson's disease" one disease? DONALD B CALNE From the Belzberg Laboratory of Clinical Neuroscience, Department of Medicine, Division ofNeurology, University Hospital, Vancouver, BC, Canada SUMMARY Consideration is given to how and why categories of ill health are divided into diseases. Aetiology is a fundamental criterion for the delineation ofindividual diseases. The same clinical and pathological picture may have many different causes; for example meningococcal meningitis and pneumococcal meningitis are distinct diseases that may display the same symptoms and signs. On the other hand, a single aetiology may lead to quite separate clinical and pathological phenomena; for example, neurosyphilis is a disorder that can present with general paresis or tabes dorsalis (or any combination of the two). In attempting to find a nosological placement for Parkinson's disease, we must take into account the extensive overlap with idiopathic dementia (Alzheimer's disease). Present evidence raises the possibility of several causes for Parkinson's disease, some of which may also be responsible for idiopathic dementia. A classification in accord with its position is desirable, and as a first step it would be helpful to replace "Parkinson's disease" with a term that is not saddled with implications of a single causal mechanism. "Idiopathic Parkinsonism" is suitable nomenclature for Protected by copyright. what is really a syndrome of unknown origin. This essay is an attempt to address the question "Is ology, epidemiology, and the natural history of dis- Parkinson's disease one disease?" From a practical eases. Sparse consideration, if any, is given to the viewpoint, a more important issue might seem "Does classification of diseases. Yet the whole framework of Parkinson's disease have one cause?', but these two knowledge of modem medicine is based upon the questions are so closely linked that an approach to the scientific and philosophical tenets that ill health former has profound implications for the latter. derives from a series of definable disturbances in the Indeed, the two questions are almost alternative structure or function ofthe body. It is inferred that the formulations of the same problem. The central role of various disorders can be grouped together according aetiology in the nosology of illness is illustrated by to similarities in clinical picture, similarities in Joseph disease, where three clinically distinct syn- mechanisms of causation, or similarities in dromes are all designated as subtypes because genetic anatomical, physiological, biochemical or path- evidence shows that they have a shared origin. The ological manifestations. It is helpful to illustrate this situation becomes more complex when we consider aspect of the nosology of diseases. For similarities of http://jnnp.bmj.com/ idiopathic syndromes. To approach this issue a clinical picture, there are "the dementias," for reasonable first step is a general consideration of how similarities of causation "the hereditary ataxias", for and why morbid entities are grouped, or separated. similarities of anatomical disturbance "the What factors underlie the classification of disease? extrapyramidal diseases," for similarities of physiological dysfunction "the epilepsies", for The problem ofclassification similarities of biochemical abnormality "the lipid Medical education focuses substantial attention on storage diseases" and for similarities in pathology "the teaching the skills of identifying diseases and treating demyelinating diseases". Many other types ofassocia- on September 26, 2021 by guest. them. Much information is also provided on path- tion between diseases exist, as in the "vascular dis- eases" the "dysimmune diseases," or the "infectious diseases". A group of diseases can also be defined by Address for reprint requests: Dr D B Caine, Department of Medicine, criteria from several different sources, for example the Division of Neurology, University Hospital, 2211 Wesbrook Mall, "axonal neuropathies" have clinical, physiological Vancouver BC, V6T lW5, Canada. and pathological features in common. In contrast, the Accepted January 1989 term "Parkinsonism" is employed for a constellation 18 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.52.Suppl.18 on 1 June 1989. Downloaded from Is "Parkinson's disease" one disease? 19 ofdisorders for which the only common denominator of Parkinson's disease, are also common in Alz- is the clinical picture. heimer's disease.' From this inconsistent background ofnosology, the If we look for analogies to these problems, they are relationships that hold the various clusters of diseases easy to find. Within neurology there are numerous together can become difficult to discern. Diseases have circumstances where (1) different diseases present with been grouped wherever there are any common features similar syndromes and (2) different syndromes are that facilitate discussing them for the purposes of caused by the same disease. For example: teaching, diagnosis, treatment, or research. But the factors that provide cohesion for each of these disci- (1) Different diseases presenting with similar syn- plines are totally different, so it is not surprising that dromes. the classification is so heterogeneous. Thejustification (a) The causes of acute meningitis may be clinically for the current situation is that the present nosology indistinguishable. To discriminate between H. influen- does "work" in the pragmatic sense that the groupings zae, N meningoccus and Str pneumoniae it is generally serve each purpose that has led to their formulation. necessary to identify the organism in the cerebrospinal It is easier to deal conceptually with disorders ifthey fluid. (b) A stroke may derive from a haemorrhage, are "lumped" rather than "split". For treatment, it is thrombosis or embolism. Clinical separation may not useful to have groups of illnesses that respond to be possible, so the neurologist frequently resorts to related drugs such as steroids, antibiotics, or vitamins. investigations such as magnetic resonance imaging. For research it seems helpful to gather disorders together into categories that are accessible to similar (2) The same disease presenting with dissimilar syn- methods of analysis. dromes By grouping morbid entities together we are making (a) Vitamin B12 deficiency may cause dementia, optic assumptions that may be quite unjustified. We cannot atrophy, subacute combined degeneration of the argue that all subjects with excessive neurofibrillary spinal cord, or a peripheral neuropathy. (b) Neurosy- Protected by copyright. tangles and plaques in the brain have the same disease philis can present with a meningovascular syndrome, any more than we can conclude that all patients with tabes dorsalis or general paresis. This last example is excessive white cells in the cerebrospinal fluid have the particularly apposite. While the syndromes of tabes same disease. However, we should not ignore the dorsalis and general paresis are quite distinct, and plaques and tangles; we need to know what causes have their own characteristic neuropathology, they them. We cannot assume that there is only one cause, also occur together with sufficient frequency for the yet that is the way we are conditioned to think if we term "taboparesis" to have been coined. The analogy group together those patients with dementia and to Parkinson's disease and Alzheimer's disease is excessive plaques and tangles under the heading of obvious. "Alzheimer's disease". We could be looking at a non- specific pathological marker analogous to inflam- To elucidate the nature of the problem further, we matory cells. Equally, ofcourse, we should not exclude must examine the bricks that make up the edifice of the possibility that there is only one cause for the our current classification of diseases, and pose the plaques and tangles; some markers, such as antibodies question "What constitutes a disease?" to motor end-plates, are highly specific. What constitutes a "disease?" http://jnnp.bmj.com/ The overlap between Parkinson's disease and Alz- Dictionaries define disease in terms of loss of health, heimer's disease and clearly infer that there must be symptoms. Dic- The discussion can now be focused more sharply on tionaries do not help us with the task of separating Parkinsonism. We know that in many patients with different diseases. However, a review of the medical advanced idiopathic Parkinsonism there is dementia literature over the last century does allow the formula- with increased numbers of plaques and tangles in the tion ofa reasonably precise concept ofthe criteria that brain at necropsy. From this finding should we argue: are likely to'be most useful in defining a disease. (1) That Parkinson's disease is a form of Alzheimer's Ifwe take examples ofdiseases which are reasonably on September 26, 2021 by guest. disease? (2) that Alzheimer's disease is a form of well understood, such as Wernicke's encephalopathy Parkinson's disease? (3) that there is an association or Wilson's disease, we can see how they emerge as between Parkinson's disease and Alzheimer's disease? distinct morbid entities. In these cases we can define a (4) that the usual criteria employed for defining these cause, a pathological picture, a pattern of clinical disease are unsatisfactory? (5) that
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