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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