Original 'Essay on the Shaking Palsy,' London: 14. Cotzias, G.C.; Van Woert, M.H.

; and Schiffer,
Macmillan & Co., Ltd., 1955, pp 145-218. L.M.: Aromatic Amino Acids and Modification of
7. Onuaguluchi, G.: Parkinsonism, London: But- Parkinsonism, New Eng J Med 276:374-379 (Feb 16)
terworth & Co., 1964. 1967.
8. Duvoisin, R.C., and Yahr, M.D.: Encephalitis 15. Cooper, I.S.: Parkinsonism: Its Medical and
and Parkinsonism, Arch Neurol 12:227-239 (March) Surgical Therapy, Springfield, Ill: Charles C Thom-
1965. as Publisher, 1961.
9. Wilkins, R.H., and Brody, I.A.: Neurological 16. Wilkins, R.H.: Neurosurgical Classic XXVII:
Classics IV: Encephalitis Lethargica, Arch Neurol J Neurosurg 22:102-125 (Jan) 1965.
18:324-328 (March) 1968. 17. Gillingham, F.J.: Stereotactic Surgery\p=m-\Past,
10. Greenfield, J.G.: "The Pathology of Parkin- Present, and Future, Clin Neurosurg 13:189-203,
son's Disease" in Critchley, M. (ed.): James Par- 1965.
kinson (1755-1824): A Bicentenary Volume of Papers 18. Spiegel, E.S.: Development of Stereoenceph-
Dealing with Parkinson's Disease, Incorporating the alotomy for Extrapyramidal Diseases, J Neurosurg
Original 'Essay on the Shaking Palsy', London: 24:433-439 (Jan) 1966.
Macmillan & Co., Ltd., 1955, pp 219-243. 19. Meyers, R.: "Historical Background and Per-
11. Earle, K.: Pathology of Extrapyramidal Dis- sonal Experiences in the Surgical Relief of Hyperki-
eases: Introduction to the Panel, J Neurosurg nesia and Hypertonus" in Fields, W.S. (ed.): Path-
24:247-249 (Jan) 1966. ogenesis and Treatment of Parkinsonism, Springfield,
12. Lewy, F.H.: Zur pathologischen Anatomie der Ill: Charles C Thomas, Publisher, 1958, pp 229-270.
Paralysis Agitans, Deutsch Z Nervenheilk 50:50-55, 20. Martin, J.P.: Remarks on the Functions of
1914. the Basal Ganglia, Lancet 1:999-1005 (Dec 5) 1959.
13. England, A.C., Jr., and Schwab, R.S.: Parkin- 21. Barbeau, A.: Some Biochemical Disorders in
son's Syndrome, New Eng J Med 265:785-791 (Oct Parkinson's Disease: A Review, J Neurosurg 24:162\x=req-\
19), 837-844 (Oct 26) 1961. 164 (Jan) 1966.

AN ESSAY ON THE SHAKING PALSY*

By
JAMES PARKINSON
Member of the Royal College of Surgeons
London: Printed by Whittingham and Rowland, Goswell Street,
for Sherwood, Neely, and Jones, Paternoster Row, 1817

Preface malady, and that analogy had suggested such

means as might be productive of relief, and per¬
.... The disease, respecting which the present haps even of cure, if employed before the disease
inquiry is made, is of a nature highly afflictive. had been too long established. He therefore con¬
Notwithstanding which, it has not yet obtained a sidered it to be a duty to submit his opinions to
place in the classification of nosologists; some have the examination of others, even in their present
regarded its characteristic symptoms as distinct and state of immaturity and imperfection. . . .

different diseases, and others have given its name

to disease differing essentially from it; whilst the Chapter I. Definition-History-Illustrative Cases
unhappy sufferer has considered it as an evil, from Shaking Palsy (Paralysis Agitans)
the domination of which he had no prospect of
escape.
(Involuntary tremulous motion, with lessened
muscular power, in parts not in action and even
The disease is of long duration: to connect,
when supported; with a propensity to bend the
therefore, the symptoms which occur in its later trunk forwards, and to pass from a walking to a
stages with those which mark its commencement,
requires a continuance of observation of the same running pace: the senses and intellects being
case, or at least a correct history of its symptoms,
uninjured )
The term Shaking Palsy has been vaguely em¬
even for several years. Of both these advantages
the writer has had the opportunities of availing ployed by medical writers in general. By some it
has been used to designate ordinary cases of Palsy,
himself; and has hence been led particularly to in which some slight tremblings have occurred;
observe several other cases in which the disease whilst by others it has been applied to certain
existed in different stages of its progress. By these anomalous affections, not belonging to Palsy. . . .

repeated observations, he hoped that he had been Tremor has been adopted, as a genus, by almost
led to a probable conjecture as to the nature of the
every nosologist; but always unmarked, in their
several definitions, by such characters as would
*Reprinted from Medical Classics 2:964-997 (June)
1938. embrace this disease. . . .

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 History directed frequently fails to raise the morsel from
the plate: which, when seized, is with much
So slight and nearly imperceptible are the first difficulty conveyed to the mouth. At this period
inroads of this malady, and so extremely slow is the patient seldom experiences a suspension of the
its progress, that it rarely happens, that the patient agitation of his limbs. Commencing, for instance
can form any recollection of the precise period of in one arm, the wearisome agitation is borne until
its commencement. The first symptoms perceived beyond sufferance, when by suddenly changing the
are, a slight sense of weakness, with a proneness to posture it is for a time stopped in that limb, to
trembling in some particular part; sometimes in commence, generally, in less than a minute in one
the head, but most commonly in one of the hands of the legs, or in the arm of the other side.
and arms. These symptoms gradually increase in Harassed by this tormenting round, the patient has
the part first affected; and at an uncertain period, recourse to walking, a mode of exercise to which
but seldom in less than twelve months or more, the sufferers from this malady are in general
the morbid influence is felt in some other part. partial; owing to their attention being thereby
Thus assuming one of the hands and arms to be somewhat diverted from their unpleasant feelings,
first attacked, the other, at this period becomes by the care and exertion required to ensure its safe
similarly affected. After a few more months the performance.
patient is found to be less strict than usual in But as the malady proceeds, even this temporary
preserving an upright posture: this being most mitigation of suffering from the agitation of the
observable whilst walking, but sometimes whilst limbs is denied. The propensity to lean forward
sitting or standing. Sometime after the appearance becomes invincible, and the patient is thereby
of this symptom, and during its slow increase, one forced to step on the toes and fore part of the feet,
of the legs is discovered slightly to tremble, and is whilst the upper part of the body is thrown so far
also found to suffer fatigue sooner than the leg of forward as to render it difficult to avoid falling on
the other side: and in a few months this limb the face. In some cases, when this state of the
becomes agitated by similar tremblings, and suffers malady is attained, the patient can no longer
a similar loss of power. exercise himself by walking in his usual manner,
Hitherto the patient will have experienced but but is thrown on the toes and forepart of the feet;
little inconvenience; and befriended by the strong being, at the same time, irresistibly impelled to
influence of habitual endurance, would perhaps take much quicker and shorter steps, and thereby
seldom think of his being the subject of disease, to adopt unwillingly a running pace. In some cases

except when reminded of it by the unsteadiness of it is found necessary entirely to substitute running
his hand, whilst writing or employing himself in for walking; since otherwise the patient, on pro¬
any nicer kind of manipulation. But as the disease ceeding only a very few paces, would inevitably
proceeds, similar employments are accomplished fall.
with considerable difficulty, the hand failing to In this stage, the sleep becomes much disturbed
answer with exactness to the dictates of the will. The tremulous motion of the limbs occur during
Walking becomes a task which cannot be per¬ sleep, and augment until they awaken the patient,
formed without considerable attention. The legs and frequently with much agitation and alarm.
are not raised to that height, or with that prompti¬ The power of conveying the food to the mouth is
tude which the will directs, so that the utmost care at length so much impeded that he is obliged to
is necessary to prevent frequent falls. consent to be fed by others. The bowels, which
At this period the patient experiences much had been all along torpid, now, in most cases,
inconvenience, which unhappily is found daily to demand stimulating medicines of very considera¬
increase. The submission of the limbs to the ble power: the expulsion of the faeces from the
directions of the will can hardly ever be obtained rectum sometimes requiring mechanical aid. As
in the performance of the most ordinary offices of the disease proceeds towards its last stage, the
life. The fingers cannot be disposed of in the trunk is almost permanently bowed, the muscular
proposed directions, and applied with certainty to power is more decidedly diminished, and the
any proposed point. As time and the disease tremulous agitation becomes violent. The patient
proceed, difficulties increase: writing can now be walks now with great difficulty, and unable any
hardly at all accomplished; and reading, from the longer to support himself with his stick, he dares
tremulous motion, is accomplished with some not venture on this exercise, unless assisted by an

difficulty. Whilst at meals the fork not being duly attendant, who walking backwards before him.

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 prevents his falling forwards, by the pressure of .... It is..
necessary to bear in mind, that
his hands against the fore part of his shoulders. this affection is distinguishable from tremor, by
.

His words are now scarcely intelligible; and he is the agitation, in the former, occurring whilst the
not only no longer able to feed himself, but when affected part is supported and unemployed, and
the food is conveyed to the mouth, so much are being even checked by the adoption of voluntary
the actions of the muscles of the tongue, pharynx, motion: whilst in the latter, the tremor is induced
etc. impeded by impaired action and perpetual immediately on bringing the parts into action.
agitation, that the food is with difficulty retained Thus an artist, afflicted with the malady here
in the mouth until masticated; and then as dif¬ treated of, whilst his hand and arm is palpitating
ficultly swallowed. Now also, from the same cause, strongly, will seize his pencil, and the motions will
another very unpleasant circumstance occurs: the be suspended, allowing him to use it for a short
saliva fails of being directed to the back part of period; but in tremor, if the hand be quite free
the fauces, and hence is continually draining from from the affection, should the pen or pencil be
the mouth, mixed with the particles of food, taken up, the trembling immediately commences.
which he is no longer able to clear from the inside II. A propensity to bend the trunk forwards, and
of the mouth. to pass from a walking to a running pace
As the debility increased and the influence of This affection, which observation seems to au¬
the will over the muscles fades away, the tremu¬ thorise the being considered as a symptom pecul¬
lous agitation becomes more vehement. It now iar to this disease, has been mentioned by few
seldom leaves him for a moment; but even when nosologists: it appears to have been first noticed
exhausted nature seizes a small portion of sleep, by Gaubius, who says, "Cases occur in which the
the motion becomes so violent as not only to muscles duly excited into the action by the im¬
shake the bed-hangings, but even the floor and pulse of the will, do then, with an unbidden
sashes of the room. The chin is now almost agility, and with an impetus not to be repressed,
immovably bent down upon the sternum. The accelerate their motion, and run before the unwill¬
slops with which he is attempted to be fed, with ing mind. It is a frequent fault of the muscles
the saliva, are continually trickling from the belonging to speech, nor yet of these alone: I have
mouth. The power of articulation is lost. The urine seen one, who was able to run, but not to walk.
and faeces are passed involuntarily; and at the last,
constant sleepiness, with slight delirium, and other Mons. de Sauvages attributes this complaint to a
marks of extreme exhaustion, announce the want offlexibility in the muscular fibres. Hence,
wished-for release. he supposes, that the patients make shorter steps,
[Six case reports follow. Three of these subjects and strive with than common exertion or
a more
were casually met or seen in the street, and were impetus the resistance; walking with
to overcome
not Parkinson's patients] a quick and hastened step, as if hurried along
against their will. . . .

Chapter II. Pathognomonic Symptoms

Examined—Tremor Coactus— Chapter III. Shaking Palsy Distinguished
Scelotyrbe Festinans From Other Diseases With Which
It May be Confounded
It has been seen in the preceding history of the
disease, and in the accompanying cases, that cer¬ Treating of a disease resulting from an assem¬
tain affections, the tremulous agitation, and the blage of symptoms, some of which do not appear
almost invincible propensity to run, when wishing to have yet engaged the general notice of the

only to walk, each of which has been considered profession, particular care is required whilst
by nosologists as distinct diseases, appear to be endeavoring to mark its diagnostic characters. . . .

pathognomonic symptoms of this malady. To de¬ Palsy, either consequent to compression of the
termine in which of these points of view these brain, or dependent on partial exhaustion of the
affections ought to be regarded, an examination energy of that organ, may, when the palsied limbs
into their nature, and an inquiry into the opinions become affected with tremulous motions, be con¬
of preceding writers respecting them, seem neces¬ founded with this disease. In those cases the
sary to be
attempted. abolition or diminution of voluntary muscular
I. Involuntary tremulous motion, with lessened action takes place suddenly, the sense of feeling
voluntary muscular power, in parts, not in action, being sometimes also impaired. But in this disease,
and even supported the diminution of the influence of the will on the

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 muscles comes on with extreme slowness, is always ity in the direction of the nervous influence; by
accompanied, and even preceded, by agitations of the wide range of parts which are affected, that the
the affected parts, and never by a lessened sense of injury is rather in the source of this influence than
feeling. The dictates of the will are even, in the merely in the nerves of the parts; by the situation
last stages of the disease, conveyed to the muscles; of the parts whose actions are impaired, and the
and the muscles act on this impulse, but their order in which they become affected, that the
actions are perverted. proximate cause of the disease is in the superior
Anomalous cases of convulsive affections have part of the medulla spinalis; and by the absence of
been designated by the term Shaking Palsy: a any injury to the senses and to the intellect, that
term which appears to be improperly applied to the morbid state does not extend to the encephalon.
these cases, independent of the want of accordance Uncertainty existing as to the nature of the
between them and that disease which has been proximate cause of this disease, is remote causes
here denominated Shaking Palsy. . . . must necessarily be referred to with indecision.
Unless attention is paid to one circumstance, Assuming however the state just mentioned as the
this disease will be confounded with those species proximate cause, it may be concluded that this
of passive tremblings to which the term Shaking may be the result of injuries of the medulla itself,
Palsies has frequently been applied. These are, or of the theca helping to form the canal in which
tremor tremulentus, the trembling consequent to it is inclosed.
. . .

indulgence in the drinking of spirituous liquors; V. Considerations Respecting

that which proceeds from the immoderate employ¬ Chapter
ment of tea and coffee; that which appears to be
The Means of Cure
dependent on advanced age; and all those trem¬ The inquiries made in the preceding pages
blings which proceed from the various circum¬ yield, it is to be much regretted, but little more
stances which induce a diminution of power in the than evidence of inference; nothing direct and
nervous system. But by attending to that circum¬
satisfactory has been obtained. All that has been
stance alone, which has been already noted as ventured to assume here, has been that the disease
characteristic of mere tremor, the distinction will depends on a disordered state of that part of the
readily be made. If the trembling limb be support¬ medulla which is contained in the cervical verte¬
ed, and none of its muscles be called into action, brae. But of what nature that morbid change is;
the trembling will cease. In the real Shaking Palsy and whether originating in the medulla itself, in
the reverse of this takes place, the agitation con¬ its membranes, or in the containing theca, is, at
tinues in full force whilst the limb is at rest and present, the subject of doubt and conjecture. But
unemployed; and even is sometimes diminished by although, at present, uninformed as to the precise
calling the muscles into employment. nature of the disease, still it ought not be consid¬

IV. Proximate Cause—Remote ered as one against which there exists no counter¬
Chapter
Causes—Illustrative Cases vailing remedy. . . .

From this review. the chance of relief from

. .

Before making the attempt to point out the the proposed mode of treatment may appear to be
nature and cause of this disease, it is necessary to sufficient to warrant its trial.
plead, that it is made under very unfavourable In such a case then, at whatever period of the
circumstances. Unaided by previous inquiries im¬ disease it might be proposed to attempt the cure,
mediately directed to this disease, and not having blood should be first taken from the upper part of
had the advantage, in a single case, of that light the neck, unless contra-indicated by any particular
which anatomical examination yields, opinions circumstance. After which vesicatories should be
and not facts can only be offered. Conjecture applied to the same part, and a purulent discharge
founded on analogy, and an attentive considera¬ obtained by appropriate use of the Sabine Lini¬
tion of the peculiar symptoms of the disease, have ment; having recourse to the application of a fresh
been the only guides that could be obtained for blister, when from the diminution of the discharg¬
this research, the result of which is, as it ought to ing surface, pus is not secreted in a sufficient
be, offered with hesitation. quantity. Should the blisters be found too incon¬
venient, or a sufficient quantity of dischargenot be
Supposed Proximate Cause
obtained thereby, an issue of at least an inch and a
.... By the nature of the symptoms we are half in length might be established on each side of
taught, that the disease depends on some irregular- the vertebral columna, in its superior part. These,

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 it is presumed, would be best formed with caustic, inconvenience for several months, it is generally
and kept open with any proper substance. . . . considered as the irremediable diminution of the
Until we are better informed respecting the nervous influence, naturally resulting from declin¬
nature of this disease, the employment of internal ing life; and remedies therefore are seldom sought
medicines is scarcely warrantable; unless analogy for.. . .

should point out some remedy the trial of which Before concluding these pages, it may be proper
rational hope might authorize. Particular circum¬ to observe once more, that an important object
stances indeed must arise in different cases, in proposed to be obtained by them is, the leading of
which the aid of medicine may be demanded: and the attention of those who humanely employ
the intelligent will never fail to avail themselves anatomical examination in detecting the causes
of any opportunity of making trial of the influence and nature of disease, particularly to this malady.
of mercury, which has in so many instances, By their benevolent labours its real nature may be
manifested its power in correcting derangement of ascertained, and appropriate modes, of relief, or
structure.
even of cure, pointed out.
The weakened powers of the muscles in the To such researches the healing art is already
affected parts is so prominent a symptom, as to be
much indebted for the enlargement of its powers
very liable to mislead the inattentive, who may of lessening the evils of suffering humanity. Little
regard the disease as a mere consequence of consti¬ is the public aware of the obligations it owes to
tutional debility. If this notion be pursued, and
those who, led by professional ardour, and the
tonic medicines, and highly nutritious diet be
dictates of duty, have devoted themselves to these
directed, no benefit is likely to be thus obtained
since the disease depends not on general weakness, pursuits, under circumstances most unpleasant and
but merely on the interruption of the flow of the forbidding. Every person of consideration and
nervous influence to the affected parts. feeling, may judge of the advantages yielded by
It is indeed much to be regretted that this the philanthropic exertions of a HOWARD; but
malady is generally regarded by the sufferers in how few can estímate the benefits bestowed on
this point of view, so discouraging to the employ¬ mankind by the labours of a MORGAGNI,
ment of remedial means. Seldom occurring before HUNTER, or BAILLIE.
the age of fifty, and frequently yielding but little Finis

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