help of some one trained to study the defects of vision. Its relief
demands, of course, as a rule, glasses, or in extra-optical
muscle-troubles these or a compensatory operation. When, however, the
vertigo has been grave, it is needful to manage corrections of the
eyes with care and judgment, and sometimes experimentally. The
sensorium, having become over-excitable, does not always bear accurate
correction of the eyes, or this increases the vertigo. Then the
glasses are cast aside and the case progresses. In others—and this is
purely a matter of individual experimentation—nothing will answer
except the most careful and absolute corrections: anything less does
no good.
These remarks apply with equal force in chronic vertigoes, essential,
gastric, or other. Defective eyes, unfelt in health, soon begin to
trouble a head sensitized by chronic dizziness, and optical defects
which are sometimes but trifling become then competent to increase the
growing intracranial disorders, or to assist lithæmia or a troublesome
stomach to create and sustain vertigo.
{428} The Status Vertiginosus.—I have tried to make clear elsewhere
and in this article that in several forms of vertigo the disorder
ceases to owe its onsets to extracentral irritations, and becomes
essential, precisely as happens in some epilepsies, and that we then
are apt to have, with more or less distinct attacks or with no
attacks, long continuance of a group of symptoms which constitute the
status vertiginosus. Its treatment is important, because of its
alarming and disqualifying effects. The attacks are often the least
part of it, while the lack of power to read and write, to go into
crowded streets, to face light, or to exercise, or stand emotions or
the slightest mental strain, surround its management with
embarrassments, and are well fitted to end in melancholia or
hypochondriasis.
In these cases, after the eye has been corrected, the diet should be
regulated with care. In extreme cases it may become desirable to limit
it to milk, fruit, and vegetables where no obvious peculiarities
forbid such a regimen; and I have found it useful to insist also on
some food being used between meals.
I like, also, that these patients rest an hour supine after each meal,
and spend much time out of doors, disregarding their tendency to lie
down. Exercise ought to be taken systematically, and if the vertigo
still forbids it, massage is a good substitute. At first near use of
the eyes is to be avoided, and when the patient resumes their use he
should do this also by system, adding a minute each day until
attainment of the limit of easy use enjoins a pause at that amount of
reading for a time.
Now, as in vertigo, especially labyrinthine, the eyes become doubly
valuable as guiding helps to correct equilibration, I have long found
it useful to train these patients to stand and walk with them closed.
At first this is as difficult, or may be as difficult, as in locomotor
ataxia, but the practice is sure to add steadiness to the postures.
Somewhat later I ask my patient deliberately to make such movements of
the head and such efforts of mind or memory as are apt to cause
vertigo or confusion of head, and to conquer or inhibit these
consequences by a prearranged effort of will; and these means also I
have found useful. Meanwhile, nothing usually in these cases forbids
the use of tonics or of moderate doses of bromides. As I have said,
change of air is very serviceable. It is indeed rare that cases do not
yield to some such combination of means, but very often it will happen
that the fears of the patient are his most grievous foes, and are to
be dealt with after every real symptom has vanished.
{429}
TREMOR.
BY WHARTON SINKLER, M.D.
Tremor is a prominent symptom of many diseases of the nervous system,
and is met with as an effect of certain poisons which have been taken
into the system; so it should not be considered as a disease in
itself. It may, however, occur without being associated with any other
abnormal condition which can be discovered. It is then called tremor
simplex or tremor essentialis. The tremor of old age (tremor senilis)
comes under this head.
Tremor is sometimes hereditary, and may exist from early life. I have
a patient in whom there is a trembling of the hands which has lasted
since childhood. This lady's mother and grandmother both had the same
form of tremor, and one of her own daughters also has it. In this case
the trembling is most marked when voluntary movements are attempted,
but it does not materially interfere with writing, sewing, or any
other act she wishes to accomplish. There is slight tremor when the
hands are at rest.
Tremor simplex is seen in hysteria. In this disease it affects the
hands and the facial muscles as well. It is not uncommon in these
cases to find the tongue tremble excessively when protruded.
Tremor from chronic poisoning is usually from the absorption of lead,
mercury, or some of the narcotic drugs or alcohol. Lead tremor is to
be looked for among persons who are exposed to the action of lead,
such as painters, printers, or manufacturers of white lead.[1] Such
persons generally have had some other symptom of lead-poisoning, such
as colic or paralysis. The tremor, however, may be the only symptom of
saturnine poisoning. Mercurial tremor is not so often seen. It occurs
in looking-glass makers or those who work in quicksilver, and may also
be a result of the medicinal administration of mercury. The tremor
from the excessive use of alcohol or opium is familiar to all.
Tobacco, if used immoderately, also causes trembling in the hands. Tea
or coffee may have the same effect. There are other drugs which, when
taken for a length of time, are liable to cause tremor. Quinine is one
of these.
[Footnote 1: Lead in hair dyes or in cosmetic powders often gives rise
to plumbism by its absorption by the skin.]
Exhausting diseases, like the fevers, or any conditions which enfeeble
the system, cause tremor which occurs in voluntary effect. I saw a
lady some years ago who was greatly weakened by a malignant growth.
She was extremely anxious to sign her name to a legal paper, but,
although the hand was perfectly quiet when at rest, when she attempted
to write {430} the first letter such intense tremor came on that it
was impossible for her to make any mark which was legible.
Tremor follows violent bodily exertion or mental excitement. The
action of cold or the chill of intermittent fever is accompanied with
an extreme degree of trembling, which we all know. Tremor is also a
result of neuritis, but in this case it is associated with other
symptoms.
SYMPTOMS.—Tremor is met with as a fine or a coarse trembling. We may
also find a fibrillar tremor, such as exists in progressive muscular
atrophy. Tremor is divided by some (Van Swieten, Charcot, and others)
into two classes: the first is where the tremor occurs while the part
is at rest; the second is where it comes on during volitional muscular
movements. The former has been termed by Van Swieten tremor coactus,
because he believed that it arose from an irritation which affected
the nervous centres in an intermittent way. The latter he conceived to
depend upon a defect of stimulus, the result of an insufficient amount
of nervous fluid, which causes contraction of the muscles under the
influence of the will. This he called tremor a debilitate.[2]
[Footnote 2: Charcot, _Lectures on Diseases of the Nervous System_.]
In paralysis agitans we have an example of tremor coactus, and in
disseminated sclerosis, where the tremor occurs only as muscular
effect, it belongs to the variety of tremor a debilitate. Those
divisions, however, are of but little importance.
When tremor first begins it is slight in degree and extent, and occurs
generally only on voluntary effort. Later there may be a constant
trembling even when the part is at rest. Beginning usually in the
hands, it may extend to the head and legs. It is seen in the tongue
and facial muscles after the disease has lasted for some time.
In some cases the trembling can be controlled to some extent by a
strong effort of will. The tremor from alcohol or opium is most marked
when the individual has been without the use of the stimulant for a
short time, and the trembling may be temporarily checked by renewing
the dose of alcohol or opium as the case may be.
The muscular trembling from plumbism and mercurial poisoning is more
violent than the other forms of simple tremor, and often resembles the
tremor of paralysis agitans. In toxic tremors there are often
secondary paretic symptoms and indications of other disturbances of
the brain and nervous system.
In simple tremor there is no loss of muscular power, and the
electrical reactions of the affected muscles are not abnormal. The
duration of simple tremor is almost always great. Usually it persists
throughout life, becoming more general and more intense as the subject
of it grows older. The tremor of hysteria is shorter in duration.
Occasionally there are seen cases of simple tremor, which are
apparently the result of some trivial cause in a nervous person, which
last but a short time.
I have seen a case of tremor of the head in a woman of about forty
years, in which the trembling ceased entirely after it had lasted
several weeks. Hammond[3] describes what he calls convulsive tremor.
Under this name he includes cases of non-rhythmical tremor or clonic
convulsions, which are unaccompanied by loss of consciousness, but are
paroxysmal in character. Pritchard in 1822 presented an account of
this affection and {431} related two cases; Hammond mentions six
cases. The affection is characterized by paroxysms of violent and
rapid convulsive movements, which are more or less general and occur
many times a day. The seizures last from a few minutes to several
hours.
[Footnote 3: _Diseases of the Nervous System_, p. 696.]
The PROGNOSIS in convulsive tremor seems to be favorable.
Tremor may be regarded as a form of clonic spasm. It consists of
slight intermittent contractions of individual muscles or groups of
muscles. Fibrillar tremor, such as is seen in progressive muscular
atrophy, depends on contractions and relaxations of the muscular
fibrillæ, and can be seen under the skin, but does not cause any
movements of the limb.
There are no pathological data for explaining what portions of the
nervous system are the seat of disease in simple tremor. In
experiments upon the lower animals it has been found that trembling
occurs in muscles which have been separated from the nerve-centres by
division of the nerve. So too in man: when there has been a wound or
section of a nerve accidentally, there is likely to be tremor in the
muscles which it supplies.
The tremor does not begin at once on section of the nerve, but comes
on after a few days. As the peripheral end of the nerve undergoes
degeneration the tremor increases. It may last months or even years.
In some of the conditions where tremor occurs the influence of the
will is weakened or is entirely absent. This is seen in hysterical
trembling and in the tremor of old age as well as in those cases where
there is general enfeeblement of the body, as in the fevers.
Trembling is connected with disease of the pyramidal tracts, because
in this way the influence of the cerebral centres is withheld from the
muscles. When a muscle is in a condition of tonic spasm, it is the
result of the running together of very rapidly-repeated muscular
contractions. It is like the contraction in a muscle from an
interrupted electrical current. If the interruptions are slow, the
muscular contractions are seen at intervals like a tremor; but if the
interruptions are rapid from frequent vibrations of the hammer of the
instrument, then the contractions in the muscle are fused together, as
it were, and the muscle is in a state of tonic spasm.
It is held by some writers that tremor is caused by the want of
balance between the cerebrum and cerebellum. When, for example, the
control of the cerebrum is enfeebled the action of the cerebellum is
so great as to bring about tremor by its uncontrolled power.
If we accept the first view, we must consider the tremor as a
preliminary stage of paralysis; for the lesion, which at first is
slight and causes only an interruption of the conduction of impulses
from the brain to the muscles, as it becomes more extensive totally
prevents conduction, and paralysis ensues.
Hughlings-Jackson's view, that general convulsions are the result of
discharges from the cortex of the brain, and that the tonic
contractions of tetanus are caused by discharges from the cortex of
the cerebellum, may be applied to the pathology of tremor as well.
When, for instance, in a disease like disseminated sclerosis a
voluntary effort instead of causing a steady muscular contraction
results in irregular spasmodic contractions and relaxations of the
muscle, we may imagine that a series of discharges were taking place
from the cortex of the cerebellum as long as the voluntary efforts
were persisted in. On the other hand, in paralysis agitans {432} it is
more probable that a lack of conducting power in the pyramidal tracts
prevents the influence of the centres being continuously exerted upon
the muscles through their motor nerves.
It is probable that in simple tremor the lesion is situated in the
spinal cord; for in this disease we seldom see any evidences of
cerebral disturbance. There are no paralytic or psychical symptoms,
and no vertigo. In toxic tremors the disease is no doubt located in
the brain, for accompanying the trembling resulting from alcohol,
opium, mercury, and other drugs are mental changes and more or less
muscular enfeeblement.
TREATMENT.—Should the tremor depend upon some cause which can be
discovered, of course the obvious course is to attempt to remove the
source of trouble. The effort is of greater or less success in
different conditions. The tremor from mercurial poisoning sometimes
yields to treatment which is directed to the elimination of the
mercury. The free administration of the iodide of potassium is the
best means to be used, and is often successful. The same means are
available in lead tremor. Of course the patient must be removed during
treatment from the risk of further absorption of the poisonous
substances.
In simple tremor many remedies have been recommended, but the results
of treatment are not encouraging. Baths of various kinds and galvanism
have been used, and many drugs are advised. Hyoscyamus and its
alkaloid, hyoscyamine, have enjoyed a high reputation, and good
results have been reported from their use. I have seen relief, but not
cure, from their administration. Arsenic is a more reliable remedy and
it may be used hypodermically. Eulenburg[4] has used this method with
good results. I have given arsenic per orem with beneficial effects in
cases of simple tremor. In a case to which I have referred above the
tremor was relieved while the patient was taking Fowler's solution,
and on changing to hyoscyamus the trembling got worse. On returning to
the arsenic the symptoms improved, and finally the tremor ceased after
the remedy had been taken for some weeks. Hysterical tremor requires
that the hysteria should be relieved. Franklinic electricity sometimes
controls the tremor in these cases.
[Footnote 4: _Ziemssen's Cyclopædia_, vol. xiv. p. 392.]
{433}
PARALYSIS AGITANS.
BY WHARTON SINKLER, M.D.
SYNONYMS.—Parkinson's disease; Shaking palsy; Trembling palsy; Senile
chorea; Chorea festinans. The first name is due to the fact that the
disease was first fully described by Parkinson in a book published in
England in 1817.
Paralysis agitans is a neurosis, chronic in its forms and
characterized by a tremor which gradually increases in extent and
severity. The tremor is not increased by voluntary muscular movements.
A peculiar manner of walking, known as festination, comes on later in
the disease, and there are also alterations in the attitude of the
head and trunk.
It is a disease which belongs to middle age, being rarely seen before
forty years, although cases are quoted by Charcot as early as twelve
and sixteen years. Constant and prolonged exposure to dampness and
cold seems to bring on the disease, and it is sometimes caused by
sudden emotion, like fear or distress. The following case is an
instance of the latter:
Case I.—Mr. A. M——, æt. fifty-two years, consulted me Oct. 1, 1883. He
is a bookbinder by occupation. His habits have been good. He had a
chancre in 1861, but had no secondary troubles. He was in the army
from 1861 until 1866. In 1866 he went into business for himself, and,
although his business was large, he had no great anxiety or worry. His
general health has been good, and he has had no illness except an
attack of malarial fever about six years ago. In May, 1883, he was
standing by an elevator door on the fourth floor of his place of
business, and, seeing that the elevator was caught by something,
released it. It immediately fell with a crash to the second floor, and
as there were two or three persons on it, Mr. M—— thought they must
have been killed or severely injured. He was greatly excited and
alarmed, and soon after he had assured himself that none of the
occupants of the elevator had been hurt, discovered a trembling of the
right hand. The tremor has continued ever since, and has extended to
the arm and leg.
On examination there is seen a coarse tremor of the right arm and leg
while the limbs are at rest. A voluntary muscular movement stops the
tremor, and it also ceases during sleep. When he makes an effort with
the right hand, as, for instance, in squeezing the dynamometer, the
tremor ceases in the arm, but becomes greatly exaggerated in the right
leg. While occupied in doing anything he does not notice the tremor,
and it stops when he is lying down.
The dynamometer shows, right hand 150°, left hand 120°. After two
years have elapsed the disease has gradually progressed in severity.
{434} SYMPTOMS.—The course of the disease has been divided into three
stages—the period of invasion, the stationary period, and the terminal
period.[1]
[Footnote 1: _Lectures on Diseases of the Nervous System_, by J. M.
Charcot.]
Period of Invasion.—There are several modes of invasion, but the most
frequent by far is slow in its onset. The disease comes on gradually,
first showing itself as a slight tremor in the hand or fingers while
the part is at rest. It is not constant, and ceases as soon as the
patient's attention is called to it. There is sometimes preceding the
tremor rheumatic or muscular pain in the affected arm. The tremor may
first occur in the foot. Should the disease begin in the hand—and this
is most common—the movements are peculiar. They may consist of a fine
rhythmical tremor, or the fingers move in a methodical way over each
other. Charcot speaks of the thumb and forefinger being rubbed
together as if the patient were spinning wool. While this movement of
the thumb and finger is going on the wrist is being flexed by jerks.
During the early stages of the disease the tremor is observed only at
intervals. It comes on intermittently when the patient is not thinking
of it and while the limb is at rest, and ceases as soon as any
voluntary muscular effort is attempted. The act of grasping the hand
or taking up an object is enough to check it for the time. In a
patient now under my care I have often noticed during the early stages
a well-marked tremor of the right hand while it was lying in her lap,
but it would at once cease when I called attention to it. As soon as
the mind of the patient was diverted to some other subject the tremor
would begin again.
As the disease progresses voluntary effort no longer controls the
tremor, or if it does at all it is only for a few seconds, when it
begins again. As the tremor increases in violence it extends to other
parts of the body. At first it may have been confined to the hand; now
it extends to the arm, a little later to the foot and leg on the same
side. Then the other arm will be affected, and finally all of the
limbs will succumb to the tremor.
Charcot speaks of decussated invasion—that is, the disease begins in
the right upper extremity, for example, and next passes to the left
lower extremity. This is a rare form; it is much more frequent to see
the hemiplegic type, which may persist for some time, or the
paraplegic type, when both legs are affected.
There is a progressive form of invasion when the tremor is not the
first symptom. The patient has neuralgic or rheumatic pains in the
limbs, which are afterward affected with tremor. Sometimes there is
some mechanical injury of the limb, which subsequently is the seat of
pain and tremor. The general health of the patient is at the same time
more or less impaired. There is a sense of general weakness and
lassitude; the temper is irritable, and there may be some vertigo. The
features and countenance are characteristic even at the earliest
periods of the disease. There is an absolute absence of expression,
and the features are fixed. The face looks like a mask, and although
the patient may smile or laugh, immediately after the features return
to the original blank expression. Amidon showed two cases of paralysis
agitans to the American Neurological Society in 1883, in which there
was no tremor whatever, but all the other features of the disease were
present.
{435} After a great mental or moral shock the trembling begins
suddenly, abrupt invasion, as in Case I., or the case described by
Charcot, where the wife of a gendarme, seeing her husband's horse
return riderless to the barracks, received a shock of great severity,
which was followed on the same day by tremor. The tremor is at first
confined to one limb. It may even disappear for a time, but gradually
and slowly extends to the other limbs, and takes the same progressive
course.
Period of Stationary Intensity.—After the disease has become fully
developed the tremor is incessant. The intensity is not the same all
the time. It may be augmented by cold, over-excitement, or voluntary
effort, and is lessened by repose and sleep. The trembling ceases
during anæsthesia.
During this time all the characteristic movements are at their height.
The moving of the thumb and finger, already referred to, is present,
and seems like a partly co-ordinated movement. Charcot describes these
movements as being in some cases like the rolling of a pencil or a
paper ball between the thumb and finger, and in others the movements,
he says, are more complicated, and are like what occur in crumbling a
piece of bread.
The handwriting is almost illegible, and every letter shows the
excessive trembling of the hand, most marked in the up strokes of the
pen. All this time the head and neck are unaffected. There is no
nodding or shaking of the head to be observed on the closest
inspection. This is an important fact to bear in mind, for it is a
distinguishing feature between the disease under consideration and
disseminated sclerosis. There is no nystagmus, and the muscles of the
jaw are unaffected by tremor. The tongue, however, while lying on the
floor of the mouth undergoes tremor, and this is increased when the
organ is protruded.
The speech is slow and jerky, and the patient usually speaks in a low
tone of voice. He eats his food without difficulty, but in advanced
cases the saliva sometimes escapes from the mouth during deglutition.
A characteristic symptom of the disease is a rigidity of the muscles
of the extremities, trunk, and of the neck. When the muscular
stiffness first begins the patient complains of cramps followed by a
sense of rigidity. The flexor muscles are first affected. This
stiffness causes peculiarities in the patient's attitudes. The head
and neck are usually bent forward, and seem fixed in that position.
The body is inclined slightly forward in standing. The elbows are held
somewhat away from the chest, the forearms are flexed on the arms, and
the hands are flexed on the forearms. The thumb and forefinger are
extended and brought together as if holding a pencil. The other
fingers are also flexed. The attitude of the hand and the prominence
of the knuckles make it closely resemble the hand of rheumatoid
arthritis. In paralysis agitans, however, there are no bony deposits
in the joints, and no cracking is heard on bending the knuckles.
In the lower extremities there is often intense rigidity. Contractions
occur, and the legs are strongly flexed. The feet often are extended
in the position of equinus. It is this rigidity which causes the
difficulty in walking (Charcot).