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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