Present Condition.—The face is expressionless and looks as if it were a mask. She articulates without using her lips to any extent, and speaks in a low tone, scanning the syllables. The head is held stiffly, and the attitude of the whole body is peculiar.
The tremor is fine, and is constant while the hands are at rest. On voluntary effort the tremor ceases. On examination with the dynamometer, right hand 95°, left hand 80°. She feels weak generally, and says she cannot use her hands even to button her clothes or to dress or undress without aid. She performs all movements slowly and with great deliberation. The patellar reflex is not excessive.
Sensation.—She has lost the sense of numbness she used to have, but says she cannot feel a needle between the fingers when she attempts to sew. There is loss of sensation in the finger-ends; the compass points are not felt at less than three lines.
Her walk is slow and deliberate like all her movements, and there is no festination. Her eyes were examined, and there was no decided change in the fundus and vision was about normal. Pupillary reflexes good.
This patient was under observation for several months, and steadily grew worse. One peculiar feature was observed, however: it was that at one time the tremor almost ceased, although all of the other symptoms were worse.
ETIOLOGY.—As already mentioned, the causes which have been observed are fright or sudden grief and prolonged exposure to cold and dampness. A number of cases of the former are mentioned by Charcot, and a case which I have related above is a good illustration of paralysis agitans produced by fright. When caused in this way the disease does not present any peculiar features in its progress or termination. I have seen many cases in which the disease had been preceded by more or less exposure to dampness. One of my patients had worked in a basement room which was damp; another (Case II.) was a great deal of the time in a kitchen which opened on a wet yard, and she was constantly going in and out of doors, getting her feet wet frequently. Sometimes irritation of a peripheral nerve seems to have been the origin of the trouble. Charcot quotes several cases of this kind.
Sex does not appear to exert any special influence in the production of the disease. Some writers assert that it is more common in males than in females, but Charcot in his large experience at La Salpêtrière has not found this to be the case.
MORBID ANATOMY.—A number of autopsies have been made in cases of paralysis agitans without any constant lesion of the nervous system having been discovered. Charcot refers to three cases in which he made careful post-mortem examinations in which the results were negative. Parkinson and Oppolzer each report one case in which was found induration of the pons, medulla, and cervical portion of the cord. More recently, however, Charcot and Joffroy have examined cases in which microscopic examination revealed blocking up of the central canal of the cord by increase of the epithelium of the ependyma and pigmentations of the ganglion-cells.
Leyden has reported a case in which the disease was confined to the right arm, and on post-mortem examination a tumor of the left optic thalamus was found.2
2 Quoted by Hamilton, Diseases of the Nervous System, p. 500.