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24. PARKINSONISM
364
Disabilities 24. PARKINSONISM A DISEASE from which one suffers oneself has a peculiar reality, and it enables one to learn the real action of the drugs recommended for its treatment, as distinct from the actions which are desired, expected, or imagined, or are memorised by examination candidates. About 20 years ago the writer began to notice in himself various symptoms of parkinsonism, which were at first attributed to suggestion, as he had by chance seen a good deal of two well-marked cases of this condition. For some time he took no diagnostic steps ; a tendency to fall forward in walking need not affect one’s capacity to earn a living, and even a considerable amount of tremor, when a steady hand is not required, may be more annoying to other people, especially when communicated to furniture, than to the patient (incidentally, a hairdresser, and a cat wishing to sleep on one’s lap, may show resentment). But extreme slowness in handwriting, due to stiffness of the thenar muscles, is not only inconvenient and time-wasting, but, when another person is waiting for what one writes, very embarrassing. Increasing inability to write at last
caused the writer to consult the late Dr. Kinnier Wilson, who was then a leading authority on such conditions. His diagnosis, made, as he said, as I entered the room, was immediate and precise, and was accompanied by the rather cheerless comment " Your face isn’t glazed yet." Possibly the condition arose during the influenza epidemic of 1918, of which the writer remembers only a period of intense sleepiness. The treatment adopted was to take seven granules, of each containing 0-5 mg. ’Genoscopolamine ’
(described
as
N-oxy-hyoscine hydrobromide*) before
breakfast. This immediately relieved the tremor and made writing possible though not easy. The good effect wears off in the latter part of the day, and for some reason a second dose is not very effectual. A trial was made of stramonium alone, but an adequate dose produces an unpleasant feeling of sleepiness and torpor and the drug was abandoned. Some non-medicinal treatment was tried also. Exercises of the " physical jerks " type lessen muscular stiffness and produce a feeling of fitness, as they do in a normal person, but they do not really make much difference. Swimming, preferably on the back, is, to those accustomed to swim in pre-parkinsonism days, much easier than walking, and eliminates the wearisome tendency to fall forward.- In deep water, one must not go on swimming until one is tired, for muscular action is then apt to stop. Curiously enough, the chief difficulty arises in shallow water, in resuming the standing position. During the past year, after about 15 years of the medicinal treatment described above, various combinations of drugs (tinctures of stramonium and belladonna, Belladonna pilocarpine, hyoscine) have been tried. has not been used in large quantities as my physician tells me that a dose sufficient to relieve the symptoms of parkinsonism would produce unpleasant eye manifestations and excessive dryness of the mouth ; but mixtures
containing stramonium, hyoscine, belladonna, and a small corrective dose of pilocarpine make it possible to enhance the desired action of each drug before producing too great an undesirable effect. Moreover, tolerance to some of the side-effects will be acquired if medication is continued. The following mixture is now used, which was arrived at by trial and error (without the knowledge of the patient, to eliminate the effects of suggestion). *
war this drug was very difficult to obtain, and friends in the United States gave invaluable help in maintaining a
During the supply.
Tincture of stramonium..... Tincture of belladonna .... Pilocarpine nitrate...... .
Hyoscine hydrobromide Water to 15 ml.
....
8 ml. (2 fl. dr.) 0-5 ml. (min. 8) 1 mg. (gr. 1/64) 0-8 mg. (gr. 1/ao)
(/2fl. oz.)
The parkinsonian has difficulty in starting to walk, and in stopping when once started ; these disabilities are never more insistent than in a picture-gallery, where the visitor’s actions must consist of a series of starts and stops. In this matter the result of the new treatment, which one may call the " picture-gallery effect," is most remarkable ; the writer was able to pay many visits to the exhibition of Indian Art at Burlington House with a degree of comfort which he had not known on such occasions for many years. An dose removes the tremor completely ; indeed, the ease with which tremor can be turned on and off suggests an excellent opportunity to investigate the metabolism of tremor: Writing becomes immensely easier, though one may never be ableto write at " scribbling" speed. Another rather annoying symptom to which this treatment brings relief is that one is apt to get " stuck " and unable to move in any unusual position of strain-e.g., when picking something up from the floor. The apparently simple movement of drying one’s hands on a towel, which to the patient is peculiarly difficult, becomes easy. When one is at the optimum stage of absorption of an optimum dose of the preparation in its best chemical state (the mixture is rather unstable) one may feel for a time just like an ordinary person-this is a very great success, and a very great
appropriate
blessing. *
*
*
The treatment has certain disadvantages : (1) An adequate dose produces considerable dryness of the mouth, and if a somewhat larger dose is taken swallowing may be impossible. This effect would provide an admirable exercise in practical physiology for students, to demonstrate the lubricating action of saliva. One must learn to take the medicine at such times that the dryness causes the minimum of trouble. Thus, if the first dose is taken after breakfast the maximum of dryness may be over before lunch. cause a certain amount of discomfort if taken without food. The gastric relation of doses to meals must be regulated by trial. The writer takes the first dose (10 ml.) just after breakfast, at which meal strong coffee is avoided as the two together are apt to cause indigestion ; the maximum dryness of the mouth is then over before midday. A second dose (5 ml.) is taken in the early afternoon, and a third (also of 5 ml.) in the evening only if it is especially desirable at that time to avoid tremor, which otherwise may reappear about 8 or 9 P.M.
(2) The medicine may
(3) One
cannot expect to have at the same time muscular relaxation and a sense of muscular fitness ; hence the medicine produces at first a considerable lassitude. At the same time there may be an increased tendency to fall forward (actually one never does fall, however imminent such a catastrophe may seem to an onlooker), which may be a result of the relaxation. This feeling of limpness and lassitude becomes much less in a few days.
on accommodation is not usually noticeable if one does not think about it. If it is perceptible when accurate vision is required, as-in reading any graduated apparatus, one must use a lens or additional spectacles.
(4) The ’effect
’
365
(5) When one has become fully accustomed the medicine, neglect to take the usual dose
to at
breakfast-time is followed by a surprising degree of nausea and sweating. Hence it is very important to keep an adequate supply at hand.
In A
.
His list comprises all the orotund, The hypochondriacs, the masochists, The psychoneurotes, and the moribund : Of cheerful convalescents mine consists. I wish I had my list and he had his.
The writer feels an
doubtless of value to themselves, which elsewhere would require the resources of a research institute.
Medicine and the Law More War Pension Cases
*
-
*
*
children’s hospital had Being house-surgeon made me discount at least half of the mothers’ statements about their children ; even more did this apply with our son, for his mother is a nurse and consequently almost as good as a doctor at fixing imaginary ills on her own offspring. So when she rang up at lunch-time to say that young James-three weeks old, healthy, and the child of reasonably normal parents-had brought in
a
"
DECISIONS on war pensions continue to accumulate. Here are three from the Scottish courts, promulgated at the end of last year. In Watson v. Minister of Pensions a soldier had died from myeloid leukaemia. In an earlier case (Thomson v. Ministry of Pensions) the court held that the tribunal was not justified in refusing a pension. The tribunal had no definite information of the aetiology of the disease and the Minister had been unable to produce evidence to negative the possible effect of Service conditions. Later it was possible to establish by medical evidence that death from myeloid leukaemia was attributable solely to natural causes, and therefore in subsequent cases the pension was refused. The widow’s appeal in Watson’s case had been held up in. view of the Thomson case. The court sent it backto the tribunal-a step which gives her the chance of any benefit to be derived from the decision in the Thomson case but which will allow the tribunal to hear the fresh evidence now available on the attributability of the disease. Two other cases went against the Minister. In Henderson v. Ministry of Pensions a soldier had suffered in childhood from otitis media. Thirteen years later it recurred in 1943. The tribunal found that the disease was not attributable to, but had been aggravated by, war service. The court awarded a pension on the ground of attributability. There had been no evidence before the tribunal that otitis media was " a continuing, latent or recurring disease," or that an attack in childhood made the patient more susceptible in later years, or that there was any connexion between the two attacks. The Minister had the onus of establishing that the 1943 attack was not attributable to war service. He had failed to do so. Finally Duff v. Minister of Pensions was the case of a soldier who suffered from nervous depression. His call-up was postponed on this account ; within 14 days of his joining his unit he committed suicide. The tribunal took the view that the neurotic condition was a result of the previous illness and that the fortnight of Army life had done nothing to aggravate it. It therefore refused the widow’s claim to a pension. The court once more reversed the tribunal’s decision. There was no evidence that Duff’s Army service did not play a part in aggravating his neurotic state. The tribunal had found that his Army life was happy enough ; this seemed to mean that the life would not have upset a normal man. That was not the test. The criterion was individual in its application-did Army service affect this particular man
BARGAIN
THE BED
My partner has my list and I have his, By some mistake each has the other’s gotten. His is a lengthy one, by gum, it is : His patients, bellyachers feeling rotten. My partner has my list and I have his.
to ascertain by trial the optimum dose and number of doses and their relation to meals, and on no account to be discouraged by the feelings of malaise, lassitude, and muscular limpness, which soon diminish, the first two rapidly and the third more slowly. The ultimate effect is to make walking very much easier, and enjoyable.
deeply grateful to his physician, who has altogether different life. And he would thank also those enigmatic plants of the Solanacese which accomplish, within the microscopic compass of their cells, organic syntheses,
Now
Running Commentary by Peripatetic Correspondents
One would advise anyone commencing the treatment
given him
England
a
"
since 6 A.M. and that she thought everything pyloric stenosis, I was suitably sceptical and patronisingly reassuring. I did, however, agree to slip home (receiving-day notwithstanding), thinking that a few sage words on the management of gastric flatulence would suffice. I was chagrined to find slight visible peristalsis, an indefinite tumour, and a very definite vomit. My reaction was " this can’t happen to us " ; but my chief confirmed the diagnosis, James doing his best to help by being so violently sick that he saturated the august personage with a mixture of stale milk and glucose water. The Rammstedt’s operation, done next day, went beautifully but was followed, as rnight be expected in a doctor’s and nurse’s child, by a wound infection The and its corollary in babies, a refusal to feed. infection was the result of parental laissez faire with a moist umbilicus, a policy that had not allowed for an upper abdominal laparotomy at three weeks ; the loss of appetite was alarming because, though everyone else seemed to consider him the picture of rude health, to my wife and me James was melting away. Massive chemotherapy and kindly attention eventually turned the scale, but it was two months before James stopped looking like a scarecrow. I find that my attitude to mothers in outpatients up
he had
tolerant and I am less inclined to when they claim that an apparently healthy baby has lost weight or is otherwise unlike his usual self. Needless to say, my wife has not allowed me to forget how I scorned her diagnosis, and James will no doubt be taught to display his scar on any future occasion when I am feeling pleased with my has become turn a deaf
clinical
more ear
acumen. *
*
*
We needed some extras to ensure the smooth working our little hospital, and we could usually get permission buy them locally. Dinner-wagons came into this category, but none of the local supply firms stocked them or had even heard of them. However, one enterprising native contractor offered to make two wagons if we supplied the plans. I made detailed drawings of a dream dinner-wagon and suggested sheet aluminium or aluminium alloy as a suitable material. Back from the contractor came a quotation which seemed not too The construction material was specified as outrageous. " 1/8 M.S.," which meant’nothing to me or the supply officer who passed the specification. The order was placed and in due course we were asked to collect the first wagon. It was made of 1/8 inch mild steel sheet and was in consequence as strong as an ammunition locker and quite as heavy. This was unhappily the only time in our experience when a native contractor had worked to specification. A sweating screaming pack of coolies pushed the monstrosity up a ramp into our truck, where it promptly fell partly through the floor. At the hospital we had
of to
Disabilities 24. PARKINSONISM A DISEASE from which one suffers oneself has a peculiar reality, and it enables one to learn the real action of the drugs recommended for its treatment, as distinct from the actions which are desired, expected, or imagined, or are memorised by examination candidates. About 20 years ago the writer began to notice in himself various symptoms of parkinsonism, which were at first attributed to suggestion, as he had by chance seen a good deal of two well-marked cases of this condition. For some time he took no diagnostic steps ; a tendency to fall forward in walking need not affect one’s capacity to earn a living, and even a considerable amount of tremor, when a steady hand is not required, may be more annoying to other people, especially when communicated to furniture, than to the patient (incidentally, a hairdresser, and a cat wishing to sleep on one’s lap, may show resentment). But extreme slowness in handwriting, due to stiffness of the thenar muscles, is not only inconvenient and time-wasting, but, when another person is waiting for what one writes, very embarrassing. Increasing inability to write at last
caused the writer to consult the late Dr. Kinnier Wilson, who was then a leading authority on such conditions. His diagnosis, made, as he said, as I entered the room, was immediate and precise, and was accompanied by the rather cheerless comment " Your face isn’t glazed yet." Possibly the condition arose during the influenza epidemic of 1918, of which the writer remembers only a period of intense sleepiness. The treatment adopted was to take seven granules, of each containing 0-5 mg. ’Genoscopolamine ’
(described
as
N-oxy-hyoscine hydrobromide*) before
breakfast. This immediately relieved the tremor and made writing possible though not easy. The good effect wears off in the latter part of the day, and for some reason a second dose is not very effectual. A trial was made of stramonium alone, but an adequate dose produces an unpleasant feeling of sleepiness and torpor and the drug was abandoned. Some non-medicinal treatment was tried also. Exercises of the " physical jerks " type lessen muscular stiffness and produce a feeling of fitness, as they do in a normal person, but they do not really make much difference. Swimming, preferably on the back, is, to those accustomed to swim in pre-parkinsonism days, much easier than walking, and eliminates the wearisome tendency to fall forward.- In deep water, one must not go on swimming until one is tired, for muscular action is then apt to stop. Curiously enough, the chief difficulty arises in shallow water, in resuming the standing position. During the past year, after about 15 years of the medicinal treatment described above, various combinations of drugs (tinctures of stramonium and belladonna, Belladonna pilocarpine, hyoscine) have been tried. has not been used in large quantities as my physician tells me that a dose sufficient to relieve the symptoms of parkinsonism would produce unpleasant eye manifestations and excessive dryness of the mouth ; but mixtures
containing stramonium, hyoscine, belladonna, and a small corrective dose of pilocarpine make it possible to enhance the desired action of each drug before producing too great an undesirable effect. Moreover, tolerance to some of the side-effects will be acquired if medication is continued. The following mixture is now used, which was arrived at by trial and error (without the knowledge of the patient, to eliminate the effects of suggestion). *
war this drug was very difficult to obtain, and friends in the United States gave invaluable help in maintaining a
During the supply.
Tincture of stramonium..... Tincture of belladonna .... Pilocarpine nitrate...... .
Hyoscine hydrobromide Water to 15 ml.
....
8 ml. (2 fl. dr.) 0-5 ml. (min. 8) 1 mg. (gr. 1/64) 0-8 mg. (gr. 1/ao)
(/2fl. oz.)
The parkinsonian has difficulty in starting to walk, and in stopping when once started ; these disabilities are never more insistent than in a picture-gallery, where the visitor’s actions must consist of a series of starts and stops. In this matter the result of the new treatment, which one may call the " picture-gallery effect," is most remarkable ; the writer was able to pay many visits to the exhibition of Indian Art at Burlington House with a degree of comfort which he had not known on such occasions for many years. An dose removes the tremor completely ; indeed, the ease with which tremor can be turned on and off suggests an excellent opportunity to investigate the metabolism of tremor: Writing becomes immensely easier, though one may never be ableto write at " scribbling" speed. Another rather annoying symptom to which this treatment brings relief is that one is apt to get " stuck " and unable to move in any unusual position of strain-e.g., when picking something up from the floor. The apparently simple movement of drying one’s hands on a towel, which to the patient is peculiarly difficult, becomes easy. When one is at the optimum stage of absorption of an optimum dose of the preparation in its best chemical state (the mixture is rather unstable) one may feel for a time just like an ordinary person-this is a very great success, and a very great
appropriate
blessing. *
*
*
The treatment has certain disadvantages : (1) An adequate dose produces considerable dryness of the mouth, and if a somewhat larger dose is taken swallowing may be impossible. This effect would provide an admirable exercise in practical physiology for students, to demonstrate the lubricating action of saliva. One must learn to take the medicine at such times that the dryness causes the minimum of trouble. Thus, if the first dose is taken after breakfast the maximum of dryness may be over before lunch. cause a certain amount of discomfort if taken without food. The gastric relation of doses to meals must be regulated by trial. The writer takes the first dose (10 ml.) just after breakfast, at which meal strong coffee is avoided as the two together are apt to cause indigestion ; the maximum dryness of the mouth is then over before midday. A second dose (5 ml.) is taken in the early afternoon, and a third (also of 5 ml.) in the evening only if it is especially desirable at that time to avoid tremor, which otherwise may reappear about 8 or 9 P.M.
(2) The medicine may
(3) One
cannot expect to have at the same time muscular relaxation and a sense of muscular fitness ; hence the medicine produces at first a considerable lassitude. At the same time there may be an increased tendency to fall forward (actually one never does fall, however imminent such a catastrophe may seem to an onlooker), which may be a result of the relaxation. This feeling of limpness and lassitude becomes much less in a few days.
on accommodation is not usually noticeable if one does not think about it. If it is perceptible when accurate vision is required, as-in reading any graduated apparatus, one must use a lens or additional spectacles.
(4) The ’effect
’
365
(5) When one has become fully accustomed the medicine, neglect to take the usual dose
to at
breakfast-time is followed by a surprising degree of nausea and sweating. Hence it is very important to keep an adequate supply at hand.
In A
.
His list comprises all the orotund, The hypochondriacs, the masochists, The psychoneurotes, and the moribund : Of cheerful convalescents mine consists. I wish I had my list and he had his.
The writer feels an
doubtless of value to themselves, which elsewhere would require the resources of a research institute.
Medicine and the Law More War Pension Cases
*
-
*
*
children’s hospital had Being house-surgeon made me discount at least half of the mothers’ statements about their children ; even more did this apply with our son, for his mother is a nurse and consequently almost as good as a doctor at fixing imaginary ills on her own offspring. So when she rang up at lunch-time to say that young James-three weeks old, healthy, and the child of reasonably normal parents-had brought in
a
"
DECISIONS on war pensions continue to accumulate. Here are three from the Scottish courts, promulgated at the end of last year. In Watson v. Minister of Pensions a soldier had died from myeloid leukaemia. In an earlier case (Thomson v. Ministry of Pensions) the court held that the tribunal was not justified in refusing a pension. The tribunal had no definite information of the aetiology of the disease and the Minister had been unable to produce evidence to negative the possible effect of Service conditions. Later it was possible to establish by medical evidence that death from myeloid leukaemia was attributable solely to natural causes, and therefore in subsequent cases the pension was refused. The widow’s appeal in Watson’s case had been held up in. view of the Thomson case. The court sent it backto the tribunal-a step which gives her the chance of any benefit to be derived from the decision in the Thomson case but which will allow the tribunal to hear the fresh evidence now available on the attributability of the disease. Two other cases went against the Minister. In Henderson v. Ministry of Pensions a soldier had suffered in childhood from otitis media. Thirteen years later it recurred in 1943. The tribunal found that the disease was not attributable to, but had been aggravated by, war service. The court awarded a pension on the ground of attributability. There had been no evidence before the tribunal that otitis media was " a continuing, latent or recurring disease," or that an attack in childhood made the patient more susceptible in later years, or that there was any connexion between the two attacks. The Minister had the onus of establishing that the 1943 attack was not attributable to war service. He had failed to do so. Finally Duff v. Minister of Pensions was the case of a soldier who suffered from nervous depression. His call-up was postponed on this account ; within 14 days of his joining his unit he committed suicide. The tribunal took the view that the neurotic condition was a result of the previous illness and that the fortnight of Army life had done nothing to aggravate it. It therefore refused the widow’s claim to a pension. The court once more reversed the tribunal’s decision. There was no evidence that Duff’s Army service did not play a part in aggravating his neurotic state. The tribunal had found that his Army life was happy enough ; this seemed to mean that the life would not have upset a normal man. That was not the test. The criterion was individual in its application-did Army service affect this particular man
BARGAIN
THE BED
My partner has my list and I have his, By some mistake each has the other’s gotten. His is a lengthy one, by gum, it is : His patients, bellyachers feeling rotten. My partner has my list and I have his.
to ascertain by trial the optimum dose and number of doses and their relation to meals, and on no account to be discouraged by the feelings of malaise, lassitude, and muscular limpness, which soon diminish, the first two rapidly and the third more slowly. The ultimate effect is to make walking very much easier, and enjoyable.
deeply grateful to his physician, who has altogether different life. And he would thank also those enigmatic plants of the Solanacese which accomplish, within the microscopic compass of their cells, organic syntheses,
Now
Running Commentary by Peripatetic Correspondents
One would advise anyone commencing the treatment
given him
England
a
"
since 6 A.M. and that she thought everything pyloric stenosis, I was suitably sceptical and patronisingly reassuring. I did, however, agree to slip home (receiving-day notwithstanding), thinking that a few sage words on the management of gastric flatulence would suffice. I was chagrined to find slight visible peristalsis, an indefinite tumour, and a very definite vomit. My reaction was " this can’t happen to us " ; but my chief confirmed the diagnosis, James doing his best to help by being so violently sick that he saturated the august personage with a mixture of stale milk and glucose water. The Rammstedt’s operation, done next day, went beautifully but was followed, as rnight be expected in a doctor’s and nurse’s child, by a wound infection The and its corollary in babies, a refusal to feed. infection was the result of parental laissez faire with a moist umbilicus, a policy that had not allowed for an upper abdominal laparotomy at three weeks ; the loss of appetite was alarming because, though everyone else seemed to consider him the picture of rude health, to my wife and me James was melting away. Massive chemotherapy and kindly attention eventually turned the scale, but it was two months before James stopped looking like a scarecrow. I find that my attitude to mothers in outpatients up
he had
tolerant and I am less inclined to when they claim that an apparently healthy baby has lost weight or is otherwise unlike his usual self. Needless to say, my wife has not allowed me to forget how I scorned her diagnosis, and James will no doubt be taught to display his scar on any future occasion when I am feeling pleased with my has become turn a deaf
clinical
more ear
acumen. *
*
*
We needed some extras to ensure the smooth working our little hospital, and we could usually get permission buy them locally. Dinner-wagons came into this category, but none of the local supply firms stocked them or had even heard of them. However, one enterprising native contractor offered to make two wagons if we supplied the plans. I made detailed drawings of a dream dinner-wagon and suggested sheet aluminium or aluminium alloy as a suitable material. Back from the contractor came a quotation which seemed not too The construction material was specified as outrageous. " 1/8 M.S.," which meant’nothing to me or the supply officer who passed the specification. The order was placed and in due course we were asked to collect the first wagon. It was made of 1/8 inch mild steel sheet and was in consequence as strong as an ammunition locker and quite as heavy. This was unhappily the only time in our experience when a native contractor had worked to specification. A sweating screaming pack of coolies pushed the monstrosity up a ramp into our truck, where it promptly fell partly through the floor. At the hospital we had
of to