In 1817 James Parkinson, a member of the Royal College of Surgeons in London, published his famous paper, An Essay on the Shaking Palsy (1). In this document he described “shaking palsy (paralysis agitans).”* This term was used in reference to a partial description given by the Greek physician Galen in the second century A.D.** Parkinson’s general description for recognizable cases was that of “involuntary tremulous motion, with lessened muscular power, in parts not in action and even when supported: with a propensity to bend the trunk forwards, and to pass from a walking to running pace…” This is, of course, a state of advanced disease with tremors, rigidity, subjective weakness, flexion of posture, and festination of gait. However, he was a student of history, a physician, scientist, and paleontologist. He knew the value of taking a detailed account of the natural history of disease, and meant not just to describe obvious or striking examples, but also to give physicians and science at large a formal understanding of the genesis of paralysis agitans. He took care to make others understand the indolent and secretive inception of this condition, which he explained is difficult to establish.
“So slight and nearly imperceptible are the first inroads of this malady, and so cextremely slow its progress, that it rarely happens, that the patient can form any recollection of the precise period of its commencement.”
He described history taken from his own patients, and in two cases, histories taken from sufferers he met on the street. The patients discussed as case examples included a 50 year-old gardener, a 62 year-old prior attendant at a magistrate’s office who, after eight years had become disabled and was the “inmate of a poor house,” a 65 year-old ex-convict of a Spanish prison, a 55 year-old man whose onset had been during an acute inflammation five years earlier, and a 72 year-old man who’d lived a life of temperance. He finally described a man he had simply observed walking in a public street. With these histories and observations, Parkinson carefully described the relentless forward march of disease in a detailed fashion reflective of his classical education. However, there was also embedded in his lengthy paper the soul of the patient, and the agony of his era, when no western medicines were known to be of benefit. Parkinson gave voice to his patient “harassed by this tormenting round,” when trying to simply eat with utensils. He described a sense of loss and the intensity of effort devoted to living with this disease.
“The submission of the limbs to the directions of the will can hardly ever be obtained in the performance of the most ordinary offices of life…Walking becomes a task which cannot be performed without considerable attention. The legs are not raised to that height, or with that promptitude which the will directs, so that the utmost care is necessary to prevent frequent falls.”
Parkinson discussed multiple motor and later non-motor issues characteristic of the disease which are commonly reported today. He reviewed key signs of disease at length and proposed a mechanism for paralysis agitans which correctly identified the brainstem as a focus of spread.
“A diseased 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.”
This work called attention to a disease which had not been described or categorized in western medicine and opened the door to 200 years of progress in the understanding, treatment, and hopefully prevention and cure. In the days of James Parkinson there were no medications in Europe known to improve symptoms. His patients were doomed to a progressive disability and no social safety net. Those without family able to care for them presumably died in the poor house, the prison, or on the street. Even in the United States, as late as the pre-levodopa era of the 1960s, some hospitals contained Parkinson’s wards in which patients who had lost the ability to walk passed their days in bed, and once completely deconditioned, often succumbed to aspiration pneumonia or deadly blood clots caused by immobility. The dawn of levodopa treatments ended those wards. Life expectancy of most PD patients became that of the general population, a huge victory which cannot be understated. Though the disease still has the potential to be devastating, we now live in a time in which we understand much of the genetic and molecular mechanisms of this incredibly complicated syndrome affecting so many systems of the human mind and body. Medications have advanced and deep brain stimulation is in common use. Ongoing trials of vaccines, monoclonal antibodies, stem cells, and other interventions give a great deal of hope. I thank James Parkinson and appreciate his discipline and deeply scientific approach, as well as his profound empathy for those who suffer under the disease of his namesake.
FOOTNOTES
* It was not Parkinson, but the French physician Charcot who would in 1850 apply Parkinson’s name as eponym.
**Ancient Ayurvedic texts refer to the syndrome of PD as Kampavata, though it appears this was unknown in western literature at the time of An Essay on the Shaking Palsy.
REFERENCE
- Sherwood, Neely, and Jones (London, 1817).
