During this time all the characteristic movements are at their height. The moving of the thumb and finger, already referred to, is present, and seems like a partly co-ordinated movement. Charcot describes these movements as being in some cases like the rolling of a pencil or a paper ball between the thumb and finger, and in others the movements, he says, are more complicated, and are like what occur in crumbling a piece of bread.
The handwriting is almost illegible, and every letter shows the excessive trembling of the hand, most marked in the up strokes of the pen. All this time the head and neck are unaffected. There is no nodding or shaking of the head to be observed on the closest inspection. This is an important fact to bear in mind, for it is a distinguishing feature between the disease under consideration and disseminated sclerosis. There is no nystagmus, and the muscles of the jaw are unaffected by tremor. The tongue, however, while lying on the floor of the mouth undergoes tremor, and this is increased when the organ is protruded.
The speech is slow and jerky, and the patient usually speaks in a low tone of voice. He eats his food without difficulty, but in advanced cases the saliva sometimes escapes from the mouth during deglutition. A characteristic symptom of the disease is a rigidity of the muscles of the extremities, trunk, and of the neck. When the muscular stiffness first begins the patient complains of cramps followed by a sense of rigidity. The flexor muscles are first affected. This stiffness causes peculiarities in the patient's attitudes. The head and neck are usually bent forward, and seem fixed in that position. The body is inclined slightly forward in standing. The elbows are held somewhat away from the chest, the forearms are flexed on the arms, and the hands are flexed on the forearms. The thumb and forefinger are extended and brought together as if holding a pencil. The other fingers are also flexed. The attitude of the hand and the prominence of the knuckles make it closely resemble the hand of rheumatoid arthritis. In paralysis agitans, however, there are no bony deposits in the joints, and no cracking is heard on bending the knuckles.
In the lower extremities there is often intense rigidity. Contractions occur, and the legs are strongly flexed. The feet often are extended in the position of equinus. It is this rigidity which causes the difficulty in walking (Charcot).
The gait of the patient now becomes very striking. He gets up from his seat slowly and with difficulty; hesitates a moment before starting to walk; then, once having made a few steps, goes at a rapid pace. The tendency is to fall forward; in order to preserve his equilibrium the patient hurries forward as if to catch up with his centre of gravity. This gait has been called paralysis festinans—festination or propulsion.
Although propulsion is the usual form the gait assumes, sometimes there is a tendency to fall or run backward. This tendency is not always apparent even when it exists. Charcot has a method of showing its existence which is very successful: when a patient is standing he pulls her slightly backward by the skirt, and this is sufficient to start a movement of retropulsion.
Propulsion and retropulsion are not necessarily always present. Many cases progress to the end without these symptoms.
As the disease advances the muscles become more rigid and the patient is confined to bed. He is, however, restless from a sense of prostration and fatigue. He is unable to turn himself, and often calls to his attendant to change his position. The sufferers from this disease, although not having actual pain, complain of disagreeable sensations. There is a constant sense of excessive heat whether the temperature of the room be high or low. In winter they cannot bear much bed-clothes at night, and prefer to wear very light clothing. Associated with this sensation of heat is often profuse perspiration (Charcot). Notwithstanding all these troublesome sensations the sensibility of the skin is not changed. Heat and cold are readily felt, and there is no anæsthesia or analgesia.
Terminal Period.—The duration of paralysis agitans is generally great. The disease may extend over many years—even as long as thirty years in some cases. As the tremors and rigidity increase in intensity the patient becomes obliged to sit all day in a chair or is confined to bed. Occasionally the tremor becomes less while the rigidity increases. The nutrition suffers, and the muscles especially become greatly wasted. Up to a certain point the intellect remains unaffected, but late in the disease the mind fails. General prostration of the whole system sets in, bed-sores occur, the urine and feces are passed unconsciously, and the patient dies of exhaustion. It is not often that the end comes in this way. It is much more frequent that some intercurrent disease, like pneumonia, ends the life of the patient. The disease is undoubtedly a most painful and trying one to both patient and physician. It lasts for years, and there is no prospect of relief. Charcot says that he has seen the terminal period last for three or four years. The following case is a fair example of the disease:
Case II.—Margaret Hays, aged fifty-four, single, applied for treatment at the Infirmary for Nervous Diseases, Oct. 9, 1882. She is housekeeper for her brother, who keeps a restaurant. She has had to be up late at night, and has had very much washing to do for many years. The kitchen in which she is most of the time is damp, and opens into a yard into which she has often to go. About two years ago she thought that she hurt herself in lifting something, and soon after this, on putting her hands from hot into cold water, suddenly felt a numbness in both forearms. One year ago she noticed tremor in both hands and both legs. The tremor interfered with her work, and has increased. She also felt as if there were loss of power.