Essay on Shaking Palsy

An Essay on the Shaking Palsy (1817) is often considered to be Parkinson’s greatest contribution to medicine.  The 66-page octavo volume describes a series of six cases, three of whom were never actually examined by Parkinson but rather observed casually on the street.  The cases differ in severity of disease and depth of observation, but Parkinson’s astute clinical descriptions capture the insidious onset and long duration of disease, asymmetry of motor signs and rest tremor, sense of weakness, flexed posture, and festinating gait.  He noted the progressive disease course with increasing immobility and dependence, disturbances of sleep, speech and bodily functions, but sparing of the “senses and intellect.”   In the Essay, Parkinson also discusses historical knowledge of tremor and gait disorders, possible etiologies and neuroanatomical localization, and proposed treatments.


Reviews of the Essay in London medical journals were overall praiseworthy although some excused Parkinson’s speculations on the basis of his reputation.  Although copies were difficult to find, knowledge of the Essay and of paralysis agitans as a clinical disorder spread throughout the medical community.  Charcot obtained a copy from Dr. Windsor, Librarian at the University of Manchester after a frustrating search and encouraged his pupils to translate this short but informative work.  In the 1860’s, Charcot coined Parkinson’s disease as an eponym for paralysis agitans and added other clinical features such as rigidity to the phenotype of the disease.  We continue to honor James Parkinson by recognizing the eponymous disorder and similar disorders with atypical features as parkinsonian syndromes.

Cover of An Essay on the Shaking Palsy (1817) owned by CG Goetz, scanned at Rush University Medical Center, Chicago, IL.  From the private collection of the late Dr. Robert Currier who generously gave his collection on James Parkinson’s to Dr. Christopher G. Goetz prior to death.

Title Page of An Essay on the Shaking Palsy
With a sense of humility that pervades several other works, Parkinson prefaces the Essay with an apology for mere conjectures regarding etiology of the shaking palsy.  However, he is compelled to share these “immature and imperfect” opinions with others and in conclusion, implores others to research this malady.  Reproductions of the Essay are readily available, and reading of this medical classic for Parkinson’s eloquent descriptions and a glimpse into neurological history in early 19th century England is highly recommended.

Table of Contents from An Essay on the Shaking Palsy (1817) owned by CG Goetz,
scanned at Rush University Medical Center, Chicago, IL.  From the private collection
of the late Dr. Robert Currier who generously gave his collection on James Parkinson’s
to Dr. Christopher G. Goetz prior to death.

Table of Contents  
The five chapters of the Essay include clinical descriptions of the disease, dissection of key features with historical background, differential diagnoses for the shaking palsy, proposed causes and neuroanatomical sites of the disorder, and considerations for treatments and cures.  The shaking palsy (paralysis agitans) is initially described by Parkinson in this often quoted, succinct passage:

       Involuntary tremulous motion, with lessened    
       muscular power, in parts not in action and even
       when supported; with a propensity to bend the trunk
      forward, and to pass from a walking to a running
      pace: the senses and intellects being uninjured.

François Boissier de Sauvages de la Croix (1706-1767)
Courtesy of the National Library of Medicine.

Citation Related to Gait Abnormalities
In Parkinson’s evaluation of gait abnormalities seen in the shaking palsy, he quotes Sauvages who distinguishes the gait of Scelotyrbe festinans from Chorea Viti

Scelotyrbe festinans, he says, is a peculiar species of scelotyrbe, in which the patients, whilst wishing to walk in the ordinary mode, are forced to run, which has seen by Carguet and by the illustrious Gaubius; a similar affection of the speech, when the tongue thus outruns the mind, is termed volubility.

With permission.  Bergman, Ron, et al. Atlas of Human Anatomy in Cross Section.
[Web document]. The University of Iowa: Virtual Hospital, 1995:[2001]. 
http://www.vh.org/adult/provider/anatomy/atlasofanatomy/plate23/08longfibremo.html

Neuroanatomical Site
Parkinson conjectures the proximate cause of the shaking palsy to be “a disease state of the medulla spinalis, in that part which is contained in the canal, formed by the superior cervical vertebrae, and extending, as the disease proceeds, to the medulla oblongata…and by the absence of any injury to the sense and to the intellect, that the morbid state does not extend to the encephalon.”  This region was at risk for injury due to increased mobility and resultant inflammation, structural alteration, thickening and ulceration of its membranes.  None of Parkinson’s six cases had pathological examinations, but he describes cases with similar clinical features such as Count de Lordat whose pathology revealed involvement of the “medulla, or its investing membranes, or theca, occasioned by simple inflammation, or rheumatic or scrophulous affection.”  It was not until the latter part of the 19th   century with observations and clinico-anatomical correlates of amyotrophic lateral sclerosis, tabes dorsalis, and multiple sclerosis from physicians such as Charcot, that understanding brain and spinal cord function further evolved.  Involvement of the substantia nigra and basal ganglia were not entertained until the late 19th century with work by Blocq and Marinesco, Brissaud, and Tretiakoff.

Galen (130-200) from Finger S. (1994) Origins of Neuroscience A History of Explorations
into Brain Function
.  Figure 1.16, p. 15.  New York, Oxford University Press.

Chapter II - Tremor
In Chapter II, Parkinson examines the pathognomic symptoms of tremor coactus and sclerotyrbe festinians and their historical origins.  He discusses different types of tremor noted by Galen, Juncker, Sylvius de la Böe, and Sauvages, recognizing descriptions since the second century.  Galen’s text “De tremore,” written between 169 and 180 AD categorized movements as voluntary or vital and distinguished tremor from palpitations. 

Casual Observations
Three of the six cases (cases II, III, and V) were not actually examined in person but observed casually in the street by Parkinson.  Despite only casual observances, Parkinson supplies various details regarding ages, occupations, medical and social histories, as well as clinical features for Cases II and III.  Particulars of Case V are unknown except for an excellent description of his gait difficulty:

It seemed to be necessary that the gentleman should be supported by his attendant, standing before him with a hand placed on each shoulder, until, by gently swaying backward and forward, he had placed himself in equipoise; when, giving the word, he would start in a running pace, the attendant sliding from before him and running forward, being ready to receive him and prevent his falling, after his having run about twenty paces.



Galen mid-15th century.  Scene of the Practice of Medicine “blood letting”.

Treatments
In his final chapter, Parkinson discusses treatments such as common 18th and 19th century practices of bleeding from the upper part of the neck and application of vesicatories with drainage of purulent discharge.  Use of internal medicines was not justified until more knowledge of the disease was available.  However, Parkinson discusses “considerations respecting the means of cure” and comments on a role for neuroprotection:

 …There appears to be sufficient reason for hoping that some remedial process may ere long be discovered, by which, at least, the progress of the disease may be stopped. It seldom happens that the agitation extends beyond the arms within the first two years…in [this] period, it is very probably, that remedial means might be employed with success: and even, if unfortunately deferred to a later period, they might then arrest the farther progress of the disease, although the removing of the effects already produced, might be hardly to be expected.


Beer Street by William Hogarth 1751 (reprinted c 1822) with permission from
McCormick Library of Special Collections, Northwestern University Library.


From Hugo, V. (1978) Les Miserables III Grandes Oeuvres.  
Paris, Hachette.  Drawings used with permission by Hachette Livre, Paris.

Epidemiologic Factors
All six cases are male, and Parkinson alludes to occupations (gardener, sailor, magistrate attendant), habits (“remarkable temperance and sobriety” vs. “indulgence in spirituous liquors”), medical ailments (Rheumatism, rib inflammation, lumbago) and preceding events (cold drafts, trauma) as possible remote causes, but does not find sufficient information to infer causation.  Case III, a sailor, “attributed his complaints to having been for several months confined in a Spanish prison, where he had, during the whole period of his confinement, lain upon the bare damp earth.”  Case VI, a man age 72 years, suffered a stroke which temporarily suppressed his tremor while his affected arm was paralyzed. 

 …On waking in the night, he found that he had nearly lost the use of the right side, and that the face was much drawn to the left side…During the time of their having remained in this state, neither the arm nor the leg of the paralytic side was in the least affected with the tremulous agitation; but as their paralysed state was removed, the shaking returned.

 

Giovanni Battista Morgagni (1682-1771)

John Hunter (1728-1793)

Matthew Baillie (1761-1823)

Conclusion
Parkinson concludes the Essay by not only elaborating on the need for research in this malady but also expressing gratitude to those who have humanely employed anatomical examinations to understand causes of diseases and find appropriate treatments or relief.  He writes:

Little is the public aware of the obligations it owes to those who, led by professional ardour, and the dictates of duty, have devoted themselves to these pursuits, under circumstances most unpleasant and forbidding. Every person of consideration and feeling, may judge of the advantages yielded by the philanthropic exertions of a Howard; but how few can estimate the benefits bestowed on mankind, by the labours of a Morgagni, Hunter, or Baillie.


Return to top of page