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Paralysis Agitans





This is a chronic affection of the nervous system having for its most
characteristic symptom a tremor, but with marked muscular rigidity and
weakness. It is much more common in men than in women, in almost the
reverse proportion of Graves' disease. It is usually a disease of the
old, but may occur in early middle life and has been known to develop
even early in the twenties. In the old days when malaria was a common
diagnosis for many different conditions, paralysis agitans apparently
followed malaria so often that there was thought to be some connection
between the two diseases. The more we have learned of malaria the less
likely this seems to be. Continuous exposure to cold for long periods
and to dampness during the daily occupation for years, or repeated
severe wettings, have been considered as causative elements. None of
these physical factors, however, has been as directly connected with
the occurrence of the affection as various emotional conditions, and
the thought is suggested that even in cases of severe exposure the
worry and fright and solicitude incident to the fear in an elderly
person that this exposure will have serious consequences, is an
important etiological element.


Psychic Factors.--Fright.--Practically all the authorities agree
that mental conditions are prominent factors in the production of the
disease. Serious business cares and worries and anxieties have often
long preceded its development. Fright is mentioned by nearly all those
who write on the subject as at least an occasion for the development
of paralysis agitans if not a cause. One of my own most interesting
cases occurred in the sheriff of a county of the Southwest who had
earned for himself the deep enmity of an Indian by arresting him. Not
long afterwards one Sunday morning when the sheriff quite unarmed came
round a corner he found the Indian just in front of him wildly drunk
and armed with a rifle. At once the rifle went to the Indian's
shoulder, but he did not want to kill his man without having his
revenge by torturing him, so he did not pull the trigger, but
announced to him in vigorous though broken English that he had him now
and was going to kill him. The sheriff tried to parley and for a
moment the Indian permitted him to do so, apparently in order to
prolong the agony. They were not more than two yards apart at the
beginning, and the sheriff took his only chance and jumped and knocked
the gun up. It went off just as he did so, the bullet singeing his
hair. He succeeded in arresting the Indian and throwing him into jail,
but the next day a tremor developed in the arm which had grasped the
rifle. This spread and finally became typical of paralysis agitans. He
was a man only slightly past fifty and there had been no preliminary
symptoms.


Mental Control of Symptoms.--Many similar cases following fright or
vehement emotion have been reported, so that it is easy to understand
the feeling that the affection has a large psychic element in it,
though evidently from its persistency and its continued development,
there is some underlying pathological condition. The tremor may be
controlled in voluntary movements, while emotion exaggerates it.
There is no doubt, however, that concentration of will and the
definite effort to control the symptoms enables the patient to rid
himself of them to a great degree for a time at least. It has been
noted frequently that when a consultant physician is called the
patient will be better for the day of the consultation than he had
been for months before. The visits of particular friends will often
arouse a sufferer to such efforts as greatly lessen his rigidity,
decrease his tremor and make him capable of getting around better than
before. The state of mental depression that commonly develops in these
cases exaggerates the symptoms, adds neurotic and even physical
conditions that develop from lack of exercise and air, and makes the
patient's general state much worse than it would otherwise be.


Pathology.--Our scanty but growing knowledge of the pathology of
paralysis agitans makes it clear that the disease is, in typical
cases, probably due to an overgrowth of connective tissue, the
neuroglia cells, in the central nervous system. Just what causes this
overgrowth of connective tissue is not clear. It is an exaggeration of
a normal senile process. Apparently one of the processes of age in man
is a decadence of the vitality of important higher tissues with a
corresponding increase of vitality in the lower or connective tissues.
When Flourens declared at a meeting of the French Academy of Sciences
that such an overgrowth of connective tissue was natural with
advancing years, he added that this probably accounted for the
slowness with which older men come to conclusions. The old members of
the Academy did not accept this new-fangled doctrine with equanimity.
They were inclined to think that their conservatism and deliberateness
were due to greater poise of intellect.

There seems to be no doubt that at least a comparative overgrowth of
connective tissue is characteristic of the brain in advancing years.
In some people this occurs to a greater extent and is more precocious
than in others. Just what causes are responsible for individual
differences we do not know. Paralysis agitans is seen often in those
who have worked hard most of their lives, but, on the other hand, may
occur in those who have lived sedentary lives, and in people of all
occupations. Over-indulgence in alcohol, though this is often thought
to predispose to the disappearance of the parenchyma of organs and to
the overgrowth of connective tissue, does not seem to have any place
in the etiology of this affection. Its occurrence is a part of that
mystery by which the equilibrium of different kinds of cells in the
body is maintained or diminished. In a mild way paralysis agitans
represents such a change in the central nervous system.


Mental Influences.--With an overgrowth of connective tissue as the
pathology of the disease there would seem to be no question of any
relief of its symptoms or any benefit to be derived from
psychotherapy. Anyone who has much to do with cases of paralysis
agitans, however, knows that they are extremely susceptible to mental
influences. Whenever there is anything that interests them, any
business that they feel they must do, any special event that they look
forward to, they will for days at a time be so much improved in
general symptoms as to be greatly encouraged themselves and make their
friends feel hopeful with regard to them. When they give in to their
condition, however, and make no special effort at self-control and
stimulation their symptoms increase very much. Their rigidity
particularly increases, their tremor becomes more marked and
various inconveniences associated with these two cardinal symptoms are
emphasized.


Methods of Treatment.--The Vibrating Chair.--It is interesting to
recall some of the forms of treatment which have been reported as
beneficial in paralysis agitans, because they illustrate how much the
influence of the patient's mind has over his bodily condition and how
much the interest aroused in any new and particularly in any unusual
form of treatment has in mitigating symptoms and how often it seems to
bring about remissions in the progress of the disease. Twenty years
ago Charcot suggested the use of a mechanically vibrating arm-chair.
He had noticed that patients who travelled by rail seemed to have
their symptoms improved for the time at least by the shaking up in the
train. This treatment undoubtedly made patients much less rigid and
much less tremulous. The improvement lasted sometimes for hours and
sometimes for days. It was tried rather extensively and everywhere
with reported good results, when first tried at least. After a time it
was found that it failed to have the desired effect. Apparently
whatever therapeutic value it had was due to the interest aroused in
the patient's mind and the consequent effort that was made to control
his muscles.


The Suspension Treatment.--When the method of treatment by
suspension became popular for cases of locomotor ataxia, the idea came
to try the same thing for paralysis agitans. Accordingly suspension
apparatuses of many kinds were used with reported good results.
Patients were suspended by the neck for some minutes and some of them
got used to the treatment and could stand it for a prolonged period.
The effect was always a distinct mitigation of symptoms. The rigidity
particularly became much less marked, but the tremor also was lessened
and besides certain secondary symptoms were bettered. Constipation was
improved, partly because patients were more cheerful, ate more
heartily and, above all, were willing to make some effort in order to
get out regularly into the air. There was a variety in life, different
from the solitary sitting at home into which these patients so often
drift. Sleep was better at night and the subjective sensations of heat
and cold were lessened. Patients were encouraged to think of
improvement and used all their available nervous energy. In the same
way when overstretching of the spinal cord by forcibly bending of the
body at the hips was tried with reported success in tabes it was also
applied to paralysis agitans with similar improvement of symptoms.
Both methods of treatment have gone out for both these affections and
evidently their observed therapeutic efficiency at first was entirely
due to their effect upon the mind.


Psychic Elements and Other Remedies.--When organo-therapeutics
became the fad paralysis agitans was treated also by this method. Some
cases were treated with reported good results by thyroid. Later when
the parathyroids attracted attention they were administered with
reported good success in even very severe cases. I think that there is
a report of some cases of paralysis agitans being improved by
injections of diphtheria serum. In other words, anything that was
given to a patient with the promise that he would be better after it
and that produced a definite effect upon his mind was likely to do him
temporary good. If the remedy had some special theory behind it, if
there was a story of some new scientific significance for the material
employed or the method of giving it, then this improvement was sure to
take place. In the drug treatment of the disease the same
principles applied. Earlier, when nitrate of silver was the main
recourse for organic nervous diseases, cases were reported improved by
its administration. When the alterative properties of arsenic became a
therapeutic fad this produced good effects. Atropin had for some time
a reputation of relieving patient's symptoms. After a time all of them
ceased to be used to any extent.


The Frenkel Method.--In recent years the application of the Frenkel
directed movement method, modified somewhat from its application in
tabes, has attracted attention in the therapeutics of paralysis
agitans. It is interesting to note how often a mode of treatment that
has been applied successfully to one of these diseases has also proved
successful with the other. The two diseases are, of course, very
different in etiology and pathology; but have one thing in common. The
control over muscles has been lost to some degree in both cases in the
progress of the disease, and a special effort of attention is required
on the part of the patient in order to regulate movement. Anything
that will arouse the patient to make this special effort will relieve
the symptoms for a while and in tabes may bring about a lasting
improvement, because the habit becomes easier after a time, though
apparently this does not occur in paralysis agitans, except perhaps in
the younger patients. It might very well be expected, then, that
Frenkel's method in many cases would do good in paralysis agitans and
it has proved to be another adjunct in the treatment of the affection.
It must be used with great care not to exhaust the patient, but this
is true also in tabes. The real source of its therapeutic quality
seems to be the patient's interest in it and if this cannot be aroused
it usually fails to do good. The success of these various mechanical
methods makes it easy to understand why these patients often improve
for a time under osteopathic treatment.


Psychotherapy.--It is clear, then, that the most important aid for
these cases is the arousing of mental interest in some form of
treatment that promises to be of benefit to them. New forms of
treatment cannot always be invented and mental occupation must be
secured by interest in other things. Patients suffering from paralysis
agitans are prone to allow themselves to give up efforts to do things
in which their interest would be aroused. They must be encouraged to
do many things. Carriage riding, automobiling, train excursions,
because of the effort required to resist vibration, are all helpful.
They must not be allowed to drift into vacuous habits in which they
make no effort for themselves. They can thus be made much more
comfortable and most of their symptoms can be relieved to a marked
degree. This requires constant attention and ever-renewed efforts to
arouse the patient's mind and to have him make such efforts as will
overcome rigidity and control the tremor to some extent; but with care
an amelioration of the condition can always be brought about and can
be maintained, at least to the extent of making the patient much more
comfortable than would otherwise be the case.





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