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Tremors





Two types of tremors come to us for treatment: those that are quite
involuntary and occur when muscles are at rest, and those that are
associated with voluntary movements. The most common type of
involuntary tremor is that seen in paralysis agitans to which a
special chapter is devoted. After this, though coming for treatment
much less frequently, is senile tremor which may, however, also be
increased by voluntary movement. The tremors associated with voluntary
movements are spoken of as intentional tremors. They may occur as the
result of organic disease of the nervous system and the most
characteristic type is that seen in multiple sclerosis. They are more
frequent, however, with functional diseases of the nervous system and
with emotional disturbances of various kinds. They are especially
frequent as the result of dreads. Usually the idea of tremor is
associated only with the head and the hands. Tremors may occur in
other parts of the body, however, and tremors of the legs are
particularly important. A familiar type is the tremor and unsteadiness
of the legs which occur as a consequence of the dread of heights when
a person unused to such situation attempts to walk across a narrow
path a great distance above the ground.


Senile Tremor.--The most common of the involuntary tremors is that
associated with old age. It develops in practically all very old
people, but it comes to some who are comparatively young. Its
occurrence at the age of fifty-five usually gives the sufferer a
severe shock which is emphasized by the attitude of mind of friends
toward the affection. They seem to be always sure that it is the index
of rapidly advancing age and that it is practically a signal of
approaching dissolution. As a matter of fact, when unassociated with
gross pathological lesions, the senile tremor has no such
significance. When associated with definite lesions it is the
prognosis of the special condition and not any supposed significance
of this particular symptom of tremor that expresses the genuine
outlook in the case. Many people who live to a very old age develop
tremor before they are threescore. Most of those who live to be eighty
or more have some tremor that develops about or just after the age of
seventy.


Significance.--Senile tremor is supposed to be due to, and in most
cases probably is the result of, an overgrowth of connective tissue in
the central nervous system which disturbs the ordinary conduction of
nerve impulses, rendering them wavering and uncertain. This seems to
indicate that it will not be long before the advancement of this
sclerotic process will make serious inroads on the vigor of the
individual. As a matter of repeated observation, however, the ordinary
involuntary tremor of old people may last twenty years.


Reassurance.--The main principle in the treatment of tremors of the
old is to make the patients realize that the symptom has no such bad
prognosis as is usually attributed to it. Of course, they will find
this out for themselves after a few years, but what they need is
assurance at the beginning lest during the period of depression
consequent upon the conclusion that the end is not far off,
which seems to be forced on them by their fears and the foolish
sympathy of friends, their resistive vitality should be so lowered as
to permit the invasion of some serious disease. In spite of
apprehensions on the part of themselves and friends, tremor is rather
a good sign than a bad one. It indicates the formation of connective
tissue in the central nervous system, but this is always a slow
process and is usually quite benign. As a matter of fact, most
sclerotic processes are so chronic as to be compensatory in their
action for many other degenerations. Those in whom tremor develops
early often seem to be better protected against rupture of cerebral
arteries, as if the growth of connective tissue was a conservative
process here also. Information of this kind helps patients not to
borrow trouble because of their condition.


Intention Tremors.--The tremors that occur in association with
voluntary movements are often very troublesome and may be difficult to
manage. The worst cases are entirely functional. They are typical
neuroses and often develop as a consequence of some serious crisis
through which the nervous system has passed. In older people they
sometimes pass over into paralysis agitans or a close simulant of that
affection. The incident of the Texas sheriff and the Indian related in
the chapter on Paralysis Agitans illustrates how these tremors may be
induced.


Tremors from Fright.--Frequently the tremors have no direct
connection with any action, though they may be the result of fright. A
little girl bitten by a dog and much shocked may, for some time
afterwards, be quite unable to stand when she sees a dog on the
street, so disturbing is the tremor that comes over her. Tremors of
the same kind have been connected with horses after the patient had
been run down in the street, and, in one case that I saw even when the
patient was only thrown out of a carriage during a runaway.
Occasionally fright by a burglar may cause a distinct tremulousness
that supervenes whenever the patient thereafter is wakened suddenly at
night.


Influence of Dread.--Tremors of all kinds can be made worse by the
dread of them. In the chapter on Dreads we discuss the disturbance of
function by dreads and especially the tendency to exaggeration of
pathological conditions of any kind when the patient's mind becomes
concentrated on it. Steadiness in any position is due to a nice
balancing of extensor and flexor muscles requiring the sending down of
a continuous stream of impulses. The equilibrium is attained and
maintained in spite of the fact that, as a rule, the flexor muscles
are stronger than the extensors and better situated to exert their
mechanical force. If anything happens to disturb this balance even to
a slight degree, the mind becomes attracted to it and there is a
corresponding result as in stuttering, or other complex function when
surveillance is too great. It is important to remember this at the
beginning of all cases of tremor, for the patient nearly always
exaggerates his tremor by attention to it and can be made so much
better by reassurance and diversion of mind that he is much encouraged
and his general health usually improves, making him feel, even though
his affection is organic, that he is being cured.

Tremors may occur in connection with almost any set of actions
requiring special co-ordination of muscles, but they are especially
likely to occur when a feeling of dread disturbs the control over
muscles. A typical example of this is noted in shaving. There are many
men who cannot shave without trembling so as to cut themselves. The
feeling that they have a sharp instrument in their hand with
which they may cut themselves sets up the tremor. There are others who
cannot shave because they dread that while using the instrument over
the important organs of the neck, and especially the blood vessels,
they may be tempted to cut their throats. This is, of course, purely a
dread and not a tremor. Some men find both the dread and the tremor
much worse at times when they are tired and worried, and can shave
very well at other times. Some men can shave very well when they are
not under observation, but if anyone is looking at them they tremble
and cut themselves. The safety razor usually does away with these
troubles, large or small, but if it should happen that by particularly
inexpert use they cut themselves even with a safety razor, especially
in the throat region, the old dread and tremor reassert themselves and
shaving becomes almost as difficult as before.


Self-consciousness.--Almost any position or action in which a man
feels himself under observation may cause one of these tremors. As a
consequence this particular set of actions may become the source of so
much discomfort as to produce an intense sense of fatigue. It may,
indeed, become quite impossible of accomplishment. Some teachers
cannot do demonstrating work on a blackboard before a large unfamiliar
class, at least not without serious efforts to control themselves,
though they may be facile demonstrators before a small class. I have
known men, however, who practically could not do blackboard work at
all because of nervousness. Their writing went all askew and very
often their thoughts would not follow one another in such order as to
make demonstrations possible. Sometimes they were good talkers, so
long as they did not turn their backs to the class and feel the eyes
of all on them. The same thing is true of such religious services as
Mass in the Catholic Church, where some of the clergymen have this
feeling. I know of priests who have not said Mass publicly for years
and others who can only say it in a small chapel before a few people
because of the intense discomfort of the fatigue caused by this state
of mind.


Stage Fright.--It is not alone the hands and the arms that tremors
are likely to affect, for they may also occur in the legs. A typical
and familiar case is the tremor that occurs upon the first appearance
before large audiences of orators or actors or clergymen. Owing to
excitement, they are unable to make flexor and extensor muscles
exactly balance each other and the consequence is a tremulous movement
that may be complicated by some swaying. Some people never lose this
in spite of long experience in public appearance. Young people may
have it upon being introduced to persons of whom they think a great
deal. This passes off with years, as a rule, but in some it persists,
and any excitement causes tremor of the legs and swaying movements.
The effort to control this is often severe and causes intense fatigue.

Any set of movements requiring even slight co-ordination of muscles
may be the subject of disturbance by a tremor. Since the writing of
the book on Pastoral Medicine, a text-book of medical information
meant to be of assistance to clergymen, [Footnote 43] I have had some
rather interesting tremors associated with the performance of clerical
duties brought to my attention. One of these is a trembling of the
legs which makes standing at a high altar almost impossible. Another
troublesome tremor is that associated with the giving of communion.
Most priests find no difficulty in the performance of the rite.
Some of them are much worried and anxious about it, however, and
develop a slight tremor. Others become so nervous in performing the
ceremony that they cannot succeed in placing the Host on the tongue of
the communicant without certain false movements. These may cause them
to touch the lips or the cheeks of the recipient and after this has
happened a few times the giving of communion becomes practically
impossible for them. Occasionally the men thus affected have no other
nervous symptoms and often they are very intelligent, strong-minded
men.

[Footnote 43: O'Malley and Walsh, "Pastoral Medicine." Longmans, 1906.]


The General Health.--Tremor patients always complain more of this
symptom when they are in a run-down condition. One of them is a
wealthy merchant who, when he can be persuaded to take a vacation,
comes back with nearly all the manifestations of his tremor latent or,
at least, well under control. Another is a broker who at the end of a
long winter of excitement and worry is at his worst, but who after a
vacation in the North Woods is quite well again. Slight symptoms of
this kind are not unusual in teachers, especially women, though I have
seen them also in men, and are much more complained of at the end of
the year when the individuals are in poorer general condition than at
any other time. The symptom itself is annoying because of the notice
that it attracts, but their dread that it may have some serious
significance, indicating the development of a progressive lesion of
the central nervous system, constitutes the worst part of their
ailment. When the intentional tremor is intermittent and occurs only
at times of excitement, or when the patients are under observation,
they can be reassured that it is merely neurotic and that no ulterior
development is to be anticipated.


Treatment.--The treatment of these conditions consists first in
bringing the patient's health up to its normal condition as far as
that is possible. Many of the sufferers from tremors are under weight.
Whenever they are, a definite, determined effort must be made to bring
them up to it. This must be done even though they insist that they
have never been heavier and that to be rather underweight is a family
trait. In many cases it will be found that this family trait, instead
of being due to some inevitable hereditary tendency, is only the
result of family habits in the matter of eating. Many of these people
do not eat substantial breakfasts. Their tremor, too, is likely to be
worse in the early morning than at any other time during the day,
unless, of course, they have become overtired during the day, when the
tremor will reassert itself with vigor. Most of them are much less
disturbed in the afternoon than before. The drug treatment of the
affection consists mainly in the use of nux vomica, but, not in the
small doses of five or ten drops so often employed, but, according to
the size of the individual, beginning with fifteen or twenty minims,
thirty or forty drops, and gradually increased to physiological
tolerance, when the dose should be set somewhat below that.


Mental Control.--The main treatment must consist, however, in
enabling the patient to secure psychic control over himself and his
muscles. This is not an easy matter. Most of them are quite
discouraged, but their attitude of mind must be changed and the real
significance of their affection made clear to them. As a rule, they
have either heard or read or been told by a physician that their
intentional tremor is significant of a serious pathological lesion of
the central nervous system. Some of them have heard of multiple
sclerosis and are much disturbed. They must be reassured and it
must be made clear to them that their disease is really due to
over-consciousness and consequent lack of control. A good deal of
reassurance can be given by telling them of patients who suffer from
ailments not unlike theirs, showing how multiform the affection is. A
man who has trouble with his signature may be told about the man who
finds it difficult to drink when under observation, then, as a rule,
he will better realize the neurotic character of his affection. With
hysterical women this method must be used with care or the story of
another patient will act as a suggestion and the physician will
subsequently be treated to an exhibition of the symptoms which he has
described.


Self-Discipline.--Persistent quiet discipline is the one thing that
eventually does any good. When patients are first told of this and are
persuaded to attempt it, they make such a determined effort to
overcome the affection that they make themselves more conscious of it
than before with the result that their tremor and spasmodic movements
are emphasized. It is the old story of the man trying to stand so
straight that he falls backwards. It must be made clear to them that
discipline, to be of any value, must be carried out as much as
possible without consciousness of it and with all available artificial
aids. The man who has trouble with his signature may be shown that he
can overcome much of the tendency to tremor and spasm of the forearm
muscles that are at the root of his difficulty by sitting at a higher
chair, so that his arm swings free of the table and so that, in
Gowers' phrase, if a pen were attached to his elbow it would write the
same thing as the pen in his hand. The man who trembles as he drinks
may be taught for a time to raise a cup to his lips while resting his
elbow on the table and bringing his head well down. Nearly always
methods of performing particular actions that require less effort can
be found, until the habit of over-consciousness and loss of control is
overcome.


Hypnotism and Waking Suggestion.--Occasionally hypnotism is
effective in these cases, but there is likely to be a relapse unless
there is some discipline before and after its use. Suggestion in the
waking state is often very effective. Patients need to be talked to
and even though intelligent they need to be reminded at regular
intervals for some time that their ailment is merely functional and
not organic. Nearly always it will be found that they trace its
beginning to some pathological event: occasionally there has been a
severe accident, but sometimes only a slight accident seems to them a
sufficient explanation. Sometimes it follows an attack of pneumonia,
oftener still typhoid fever. In these cases the patients become
convinced that this is one of the marks left after the accident or
disease and so it is rather hard to persuade them that they can be
cured. All such impressions, which act as auto-suggestions for the
continuance of their tremor and lack of control, must be combated,
otherwise there is very little hope of improvement. The preceding
disease is not the direct cause, though the weakness consequent upon
it may predispose to the tremor. Overhaste in attempting to resume
their occupations before their strength has returned is often the real
cause. It is the patient's mind more than his body that needs to be
set in order, but this will not be possible unless the physical
condition is normal and thorough reassurance can be given.





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Previous: Stuttering Ataxia In Talking Walking Writing Etc



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