TREMORS.
Paralysis Agitans (Parkinson's Dis ease).
Definition. — An affection character ized by a special form of tremor, muscu lar rigidity, and attended with paralysis.
Symptoms.—The tremor of paralysis agitans possesses characteristics that are not observed in other forms. As a rule, it appears insidiously, though it may ap pear suddenly after a fright, a violent emotion, or a traumatism. It affects first the hand, the thumb, or the foot, but it is so slight that the patient hardly perceives it. It then disappears, and soon reappears with more or less in crease in the area involved, and some times accompanied by hemiplegia and paraplegia. The peculiarity of the tremor is mainly due to the position as sumed by the extremity affected. The fingers, for instance, assume the position required to hold a pen, the four straight ened fingers united at their tips, tremble simultaneously, while the thumb oscil lates rapidly and synchronously in their direction. These movements occur while the muscles are at rest, but cease when the patient is asleep. Under the influ ence of the will their intensity may be reduced to a certain extent. The arms, legs, feet, and head may take part in the tremor, although the motion of the latter is mainly communicated to it by that of the extremities. Localized sweating is sometimes observed.
The muscular rigidity is a special feat ure of paralysis agitans. It begins by painful cramps which, though temporary at first, finally become permanent. Under the influence of this rigidity, the head, trunk. and the limbs assume spe cial positions. The head may remain fixed in position, the eyes become fixed, and the features expressionless. As re cently shown by Frenkel„ there is a well marked irregular thickening of the skin and a peculiar adherence to the sub cutaneous tissues. This is especially marked over the forehead.
Later on, the muscular rigidity causes the thighs to become rapidly raised toward the abdomen, but there is no true contracture nor the epileptoid tremor of lateral sclerosis. The hands through muscular rigidity may become deformed. Besides the cramps already alluded to, the patient complains of a sensation of excessive heat, showing thermometrically an excess of 6° F. in some cases (Gowers). In some instances tremor is absent. Later on a peculiar paresis termed the "paralytic period" appears, the tremor becoming reduced in proportion, and the patient enters a cachectic period during which disorders of nutrition occur. He gradually sinks into a marasmus, with diarrhoea, ana sarca, incontinence of urine, and gradual reduction of mental powers. An inter current affection, especially pneumonia, usually closes the scene (Dieulafoy).
Etiology and Pathology. — Although paralysis agitans is a disease of middle or advanced age, it is occasionally ob served in young subjects and more fre quently in males than females. Anxiety, worriment, violent emotions, exposure, traumatism involving a nerve, infec tious fevers, and heredity are recognized as causative factors. The exact nature of the morbid lesions is as yet unknown.
Treatment. — The bromides in large closes have been recommended, but their value is problematical. Far more useful are hot baths at a temperature of 122° F.; cold effusions on the head and ap plications of ice to the region of the fis sure of Rolando; and galvanic or electro static baths. Subcutaneous injections of a 4-per-cent. solution of sodium phos phate diminish the Parkinsonian trem bling, according to Liegeois. When the disease has evidently followed exposure to cold and wet, sodium salicylate or salol is recommended.
The drugs found of decided value in the palliative treatment of paralysis agitans are hyoseine hydrobromate, duboisine sulphate, and hyoscyamine.
llyoseine hydrobromate is the most useful. llyoseine is a very powerful drug, and it is important to be very cautious with respect to the dose and mode of administration. It is best to give the drug by mouth in paralysis agitans. At first the dose should not be more than '/,, grain. This may be increased up to grain. If no toxic symptoms appear, such as marked dryness of the throat and dilated pupils, the dose may be cautiously increased. In paralysis agitans the dose may often be increased up to V, 'I,,, or even grain without bad effects, except dryness of the throat. But such large doses should only be given when the patient is in hospital, or can be very carefully and frequently watched. Merck's hyoscine hydrobro mate is the best. It is important to always use the same preparation of hy oscine, as probably the strengths of dif ferent preparations vary somewhat. It is best to give the hyoscine well diluted with chloroform-water. A prescription which is useful is '/, grain of hyos chic hvdrobromate in 6 ounces of chlo roform-water. At first 2 teaspoonfuls of this may ue given; then 3, 4, or 5 teaspoonfuls administered. If neces sary, the dose may be increased to 6 tea spoonfuls grain), providing toxic symptoms are not produced. The hyos cine is best given in the morning, just after breakfast, and again in the even ing, just before going to bed, if the pa tient is troubled with restlessness and sleeplessness during the night. R. T. Williamson (Med. Chronicle, Feb., 1901).