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 J Neuropsychiatry Clin Neurosci 14:2, Spring 2002 223
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 An Essay on the Shaking Palsy
, by James Parkinson, was originallypub-lished as a monograph by Sherwood, Neely, and Jones(London,1817).Punctuation and spelling follow the original text. Introduction Copy-right
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 2002 American Psychiatric Publishing, Inc.
An Essay on the ShakingPalsy
 James Parkinson, Member of the RoyalCollege of Surgeons
PREFACE
The advantages which have been derived from the cau-tion with which hypothetical statements are admitted,are in no instance more obvious than in those scienceswhich more particularly belong to the healing art. Ittherefore is necessary, that some conciliatory explana-tion should be offered for the present publication: inwhich, it is acknowledged, that mere conjecture takesthe place of experiment; and, that analogy is the substi-tute for anatomical examination, the only sure founda-tion for pathological knowledge.When, however, the nature of the subject, and the cir-cumstances under which it has been here taken up, areconsidered, it is hoped that the offering of the followingpages to the attention of the medical public, will not beseverely censured. The disease, respecting which thepresent inquiry is made, is of a nature highly afflictive.Notwithstanding which, it has not yet obtained a placein the classification of nosologists; some have regardedits characteristic symptoms as distinct and different dis-eases, and others have given its name to diseases differ-ing essentially from it; whilst the unhappy sufferer hasconsidered it as an evil, from the domination of whichhe had no prospect of escape.The disease is of long duration: to connect, therefore,the symptoms which occur in its later stages with thosewhich mark its commencement, requires a continuanceof observation of the same case, or at least a correct his-tory of its symptoms, even for several years. Of boththese advantages the writer has had the opportunitiesof availing himself, and has hence been led particularlyto observe several other cases in which the disease ex-isted in different stages of its progress. By theserepeatedobservations, he hoped that he had been led to a prob-able conjecture as to the nature of the malady, and thatanalogy had suggested such means as might be produc-tive of relief, and perhaps even of cure, if employed be-fore the disease had been too long established. Hethere-fore considered it to be a duty to submit his opinions tothe examination of others, even in their present state of immaturity and imperfection.To delay their publication did not, indeed, appear to be warrantable. The disease had escaped particular no-tice; and the task of ascertaining its nature and cause byanatomical investigation, did not seem likely tobetakenup by those who, from their abilities and opportunities,were most likely to accomplish it. That these friends tohumanity and medical science, who have already un-veiled to us many of the morbid processes by whichhealth and life is abridged, might be excited to extendtheir researches to this malady, was much desired; andit was hoped, that this might be procured by the pub-lication of these remarks.Should the necessary information be thus obtained,the writer will repine at nocensurewhichtheprecipitatepublication of mere conjectural suggestions may incur: but shall think himself fully rewarded by having excitedthe attention of those, who may point out the most ap-propriate means of relieving a tedious and most dis-tressing malady.
CHAPTER I. DEFINITION–HISTORY–ILLUSTRATIVE CASES
Shaking Palsy (
Paralysis Agitans
)
Involuntary tremulous motion, with lessenedmuscular power, in parts not in action and evenwhen supported; with a propensity to bend thetrunk forwards, and to pass from a walking to arunning pace: the senses and intellects being un-injured.The term Shaking Palsy has been vaguely employed by medical writers in general. By some it has been usedto designate ordinary cases of Palsy, in which someslight tremblings have occurred; whilst by others it has been applied to certain anomalous affections, not be-longing to Palsy.The shaking of the limbs belonging to this diseasewasparticularly noticed, as will be seen when treating of thesymptoms, by Galen, who marked its peculiar character by an appropriate term. The same symptom, it will also be seen, was accurately treated of by Sylvius de la Boe¨.
 
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*Synopsis Nosologiae Methodicae.—Tom. ii. p. 195.
 Juncker also seems to have referred to this symptom:having divided tremor into active and passive, he saysof the latter, “ad affectus semiparalyticos pertinant; dequalibus hic agimus, quique
 tremores paralytoidei
 vocan-tur.” Tremor has been adopted, as a genus, by almostevery nosologist; but always unmarked, in their severaldefinitions, by such characters as would embrace thisdisease. The celebrated Cullen, with his accustomed ac-curacy observes, “Tremorem, utpote semper sympto-maticum, in numerum generum recipere nolem; speciesautem a Sauvagesio recensitas, prout mihi vel astheniaevel paralysios, vel convulsionis symptomata esse viden-tur, his subjungam.”
*
Tremor can indeed only be consid-ered as a symptom, although several species of it must be admitted. In the present instance, the agitation pro-duced by the peculiar species of tremor, which here oc-curs, is chosen to furnish the epithet by which this spe-cies of Palsy, may be distinguished.
History
So slight and nearly imperceptible are the first inroadsof this malady, and so extremely slow its progress, thatit rarely happens, that the patient can form any recol-lection of the precise period of its commencement. Thefirstsymptomsperceivedare,aslightsenseofweakness,with a proneness to trembling in some particular part;sometimes in the head, but most commonly in one of the hands and arms. These symptoms gradually in-crease in the part first affected; and at an uncertain pe-riod, but seldom in less than twelvemonths or more, themorbid influence is felt in some other part. Thus assum-ing one of the hands and arms to be first attacked, theother, at this period becomes similarly affected. After afew more months the patient is found to be less strictthan usual in preserving an upright posture: this beingmost observable whilst walking, but sometimes whilstsitting or standing. Sometime after the appearance of this symptom, and during its slow increase, one of thelegs is discovered slightly to tremble, and is also foundto suffer fatigue sooner than the leg of the other side:and in a few months this limb becomes agitated by simi-lar tremblings, and suffers a similar loss of power.Hitherto the patient will have experienced but littleinconvenience; and befriended by the strong influenceof habitual endurance, would perhaps seldom think of his being the subject of disease, except when remindedof it by the unsteadiness of his hand, whilst writing oremploying himself in any nicer kind of manipulation.But as the disease proceeds, similar employments areaccomplished with considerable difficulty, the hand fail-ing to answer with exactness to the dictates of the will.Walking becomes a task which cannot be performedwithout considerable attention. The legs are not raisedto that height, or with that promptitude which the willdirects, so that the utmost care is necessary to preventfrequent falls.At this period the patient experiences much incon-venience, which unhappily is found daily to increase.The submission of the limbs to the directions of the willcan hardly ever be obtained in the performance of themost ordinary offices of life. The fingers cannot be dis-posed of in the proposed directions, and applied withcertainty to any proposed point. As time and the diseaseproceed, difficulties increase: writing can now be hardlyat all accomplished; and reading, from the tremulousmotion, is accomplished with some difficulty. Whilst atmeals the fork not being duly directed frequently failsto raise the morsel from the plate: which, when seized,is with much difficulty conveyed to the mouth. At thisperiod the patient seldom experiences a suspension of the agitation of his limbs. Commencing, for instance inone arm, the wearisome agitation is borne until beyondsufferance, when by suddenly changing the posture it isfor a time stopped in that limb, to commence, generally,in less than a minute in one of the legs, or in the arm of the other side. Harassed by this tormenting round, thepatient has recourse to walking, a mode of exercise towhich the sufferers from this malady are in general par-tial; owing to their attention being thereby somewhatdiverted from their unpleasant feelings, by the care andexertion required to ensure its safe performance.But as the malady proceeds, even this temporary mit-igation of suffering from the agitation of the limbs isdenied. The propensity to lean forward becomes invin-cible, and the patient is thereby forced to step on thetoes and fore part of the feet, whilst the upper part of the body is thrown so far forward as to render it difficultto avoid falling on the face. In some cases, when thisstate of the malady is attained, the patient can no longerexercise himself by walking in his usual manner, but isthrown on the toes and forepart of the feet; being, at thesame time, irresistibly impelled to take much quickerand shorter steps, and thereby to adopt unwillingly arunning pace. In some cases it is found necessary en-tirely to substitute running for walking; since otherwisethe patient, on proceeding only a very few paces, wouldinevitably fall.In this stage, the sleep becomes much disturbed. Thetremulous motion of the limbs occur during sleep, andaugment until they awaken the patient, and frequently
 
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with much agitation and alarm. The powerofconveyingthe food to the mouth is at length so much impeded thathe is obliged to consent to be fed by others. The bowels,which had been all along torpid, now, in most cases,demand stimulating medicines of very considerablepower: the expulsion of the faeces from the rectumsometimes requiring mechanical aid. As the diseasepro-ceeds towards its last stage, the trunk is almost perma-nently bowed, the muscular power is more decidedlydiminished, and the tremulous agitation becomes vio-lent. The patient walks now with great difficulty, andunable any longer to support himself with his stick, hedares not venture on this exercise, unless assisted by anattendant, whowalking backwardsbeforehim,preventshis falling forwards, by the pressure of his handsagainstthe fore part of his shoulders. His words are nowscarcely intelligible; and he is not only no longer able tofeed himself, but when the food is conveyed to themouth, so much are the actions of the muscles of thetongue, pharynx, &c. impeded by impaired action andperpetual agitation, that the food is with difficulty re-tained in the month until masticated; and then as diffi-cultly swallowed. Now also, from the same cause, an-other very unpleasant circumstance occurs: the salivafails of being directed to the back part of the fauces, andhence is continually draining from the mouth, mixedwith the particles of food, which he is no longer able toclear from the inside of the mouth.As the debility increases and the influence of the willover the muscles fades away, the tremulous agitation becomes more vehement. It now seldom leaves him fora moment; but even when exhausted nature seizes asmall portion of sleep, the motion becomes so violent asnot only to shake the bed-hangings, but even the floorand sashes of the room. The chin is now almost im-moveably bent down upon the sternum. The slops withwhich he is attempted to be fed, with the saliva, arecontinually trickling from the mouth. The power of ar-ticulation is lost. The urine and faeces are passed invol-untarily; and at the last, constant sleepiness, with slightdelirium, and other marks of extreme exhaustion, an-nounce the wished-for release.
Case I.
Almost every circumstance noted in the preceding de-scription, was observed in a case which occurredseveralyears back, and which, from the particular symptomswhich manifested themselves in its progress; from thelittle knowledge of its nature, acknowledged to be pos-sessed by the physician who attended; and from themode of its termination; excited an eagerwishtoacquiresome further knowledge of its nature and cause.The subject of this case was a man rather more thanfifty years of age, who had industriously followed the business of a gardener, leading a life of remarkable tem-perance and sobriety. The commencementofthemaladywas first manifested by a slight trembling of the lefthand and arm, a circumstance which he was disposedto attribute to his having been engaged for several daysin a kind ofemploymentrequiringconsiderableexertionof that limb. Although repeatedly questioned, he couldrecollect no other circumstance which he could consideras having been likely to have occasioned his malady. Hehad not suffered much from Rheumatism, or been sub- ject to pains of the head, or had ever experienced anysudden seizure which could be referred to apoplexy orhemiplegia. In this case, every circumstance occurredwhich has been mentioned in the preceding history.
Case II.
The subject of the case which was next noticed was ca-sually met with in the street. It was a man sixty-twoyears of age; the greater part of whose life had beenspent as an attendant at a magistrate’s office. He hadsuffered from the disease about eight or ten years. Allthe extremities were considerably agitated, the speechwas very much interrupted, and the body much bowedand shaken. He walked almost entirely on the fore partof his feet, and would have fallen every step if he hadnot been supported by his stick. He described the dis-ease as having come on very gradually, and as being,according to his full assurance, the consequence of con-siderable irregularities in his mode of living, and par-ticularly of indulgence in spirituous liquors. He was theinmate of a poor-house of a distant parish, and beingfully assured of the incurable nature of his complaint,declined making any attempts for relief.
Case III.
The next case was also noticed casually in the street.Thesubject of it was a man of about sixty-five years of age,of a remarkable athletic frame. The agitation of thelimbs, and indeed of the head and of the whole body,was too vehement to allow it to be designated as trem- bling. He was entirely unable to walk; the body beingso bowed, and the head thrown so forward, as to obligehim to go on a continued run, and to employ his stickevery five or six steps to force him more into an uprightposture, by projecting the point of it with great forceagainst the pavement. He stated, that he had been asailor, and attributed his complaints to having been forseveral months confined in a Spanish prison, where hehad, during the whole period of his confinement, lainupon the bare damp earth. The disease had here contin-ued so long, and made such a progress, as to afford littleor no prospect of relief. He besides was a poor mendi-

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