Parkinsonism: From 3 Different Sources
Parkinsonism, or paralysis agitans, is a progressive disease of insidious onset usually occurring in the second half of life; it is much more common in men than in women. Degenerative changes in the basal ganglia (see BASAL GANGLION) lead to a de?ciency in the NEUROTRANSMITTER, DOPAMINE – or occasionally in other neurotransmitters – and it is this de?ciency that is responsible for most cases.
The clinical picture is characterised by TREMOR, rigidity and poverty of spontaneous movements. The loss of natural play of expression in the face produces a mask-like expression. Rigidity of the larynx, tongue and lips produces a ?at, expressionless voice. The most common symptom is tremor, often affecting one hand, spreading to the leg on the same side, then to the other limbs. It is more pronounced in resting limbs and is exaggerated by excitement, stopping during sleep. It may interfere with eating and dressing. Limb rigidity leads to an increasing tendency to stoop. The patient has a shu?ing walk with a peculiar running gait.
Treatment Several drugs are used to keep the condition under control. None is curative, all have side-effects, and ?nding the most suitable one for any individual depends largely on understanding cooperation between family doctor and patient. Dopaminergic and antimuscarinic (see ANTIMUSCARINE) drugs are used in treatment. Levodopa, a precursor of dopamine, is a long-used example of the former; it produces spectacular improvement in one-?fth and moderate improvement in two-?fths of patients. Benzhexol hydrochloride is one of several antimuscarinic drugs used in Parkinson’s disease; selegiline is a monoamine-oxidase inhibitor used in severe parkinsonism in conjunction with levodopa to reduce ‘end-of-dose’ deterioration. Adverse effects include HYPOTENSION, nausea and vomiting, confusion, and agitation. Some drugs used to treat other disorders produce Parkinsonian side-effects. Patients seeking further advice and help, together with their relatives, are advised to contact the Parkinson’s Disease Society of the UK.
Parkinson’s disease characterised by rigidity of muscles and tremor of the hands
(akinetic rigid syndrome) n. a clinical picture characterized by tremor, rigidity, slowness of movement, and postural instability. The commonest symptom is tremor, which often affects one hand, spreading first to the leg on the same side and then to the other limbs. It is most pronounced in resting limbs, interfering with such actions as holding a cup. The patient has an expressionless face, an unmodulated voice, an increasing tendency to stoop, and a shuffling walk. Parkinsonism is a disease process affecting the basal ganglia of the brain and associated with a deficiency of the neurotransmitter *dopamine. Sometimes a distinction is made between Parkinson’s disease, a degenerative disorder, and parkinsonism due to other causes. For example, it may be induced by the long-term use of *antipsychotic drugs and uncommonly it can be attributed to the late effects of *encephalitis or coal-gas poisoning, or to *Wilson’s disease, or to multiple strokes (vascular parkinsonism). Other syndromes of which parkinsonism is a feature are *multiple system atrophy and *progressive supranuclear palsy. Relief of the symptoms may be obtained with *antimuscarinic drugs, dopamine-receptor agonists (see dopamine), *levodopa, and subcutaneous *apomorphine injections and infusions. New surgical treatments include stereotactic *pallidotomy and pallidal stimulation. The latter procedure involves placing an electronic stimulator in the globus pallidus that can be controlled by an external switch or control panel. [J. Parkinson (1755–1824), British physician]
Loss or impairment of voluntary movement, or immobility. It is characteristically seen in PARKINSONISM.... akinesia
Athetosis is the name for slow, involuntary writhing and repeated movements of the face, tongue, hands and feet, caused by disease of the brain. It is usually a manifestation of CEREBRAL PALSY. Drugs used to treat PARKINSONISM can also cause athetosis.... athetosis
Chorea, or St Vitus’s dance, is the occurrence of short, purposeless involuntary movements of the face, head, hands and feet. Movements are sudden, but the affected person may hold the new posture for several seconds. Chorea is often accompanied by ATHETOSIS, when it is termed choreoathetosis. Choreic symptoms are often due to disease of the basal ganglion in the brain. The withdrawal of phenothiazines may cause the symptoms, as can the drugs used to treat PARKINSONISM. Types of chorea include HUNTINGTON’S CHOREA, an inherited disease, and SYDENHAM’S CHOREA, which is autoimmune. There is also a degenerative form – senile chorea.... chorea
A precursor of DOPAMINE and NORADRENALINE. Levodopa is a drug used in the treatment of PARKINSONISM. It can cross the blood–brain barrier and increase the concentration of dopamine in the basal ganglia. It also inhibits prolactin secretion and may be used to treat GALACTORRHEA.... dopa
The involuntary quickening of gait seen in some nervous diseases, especially in PARKINSONISM.... festination
A drug used in the treatment of PARKINSONISM. It is converted to DOPAMINE in the brain, correcting the de?ciency which causes the disorder. Levodopa is often given with carbidopa or benserazide, both dopamine decarboxylase inhibitors, to prevent its conversion to dopamine in the body before it reaches the brain. It may cause nausea, HYPOTENSION or cardiac DYSRHYTHMIA.... levodopa
Encephalitis means in?ammation or infection of the brain, usually caused by a virus; it may also be the result of bacterial infection. It occurs throughout the world and affects all racial groups and ages. Rarely it occurs as a complication of common viral disease such as measles, mumps, glandular fever, or chickenpox. It may occur with no evidence of infection elsewhere, such as in HERPES SIMPLEX encephalitis, the most common form seen in Europe and America. RABIES is another form of viral encephalitis, and the HIV virus which causes AIDS invades the brain to cause another form of encephalitis (see AIDS/HIV). In some countries – North and South America, Japan and east Asia and Russia
– there may be epidemics spread by the bite of mosquitoes or ticks.
The clinical features begin with in?uenza-like symptoms – aches, temperature and wretchedness; then the patient develops a headache with drowsiness, confusion and neck sti?ness. Severely ill patients develop changes in behaviour, abnormalities of speech, and deterioration, sometimes with epileptic seizures. Some develop paralysis and memory loss. CT (see COMPUTED TOMOGRAPHY) and MRI brain scans show brain swelling, and damage to the temporal lobes if the herpes virus is involved. ELECTROENCEPHALOGRAPHY (EEG), which records the brainwaves, is abnormal. Diagnosis is possible by an examination of the blood or other body ?uids for antibody reaction to the virus, and modern laboratory techniques are very speci?c.
In general, drugs are not e?ective against viruses – antibiotics are of no use. Herpes encephalitis does respond to treatment with the antiviral agent, aciclovir. Treatment is supportive: patients should be given painkillers, and ?uid replacement drugs to reduce brain swelling and counter epilepsy if it occurs. Fortunately, most sufferers from encephalitis make a complete recovery, but some are left severely disabled with physical defects, personality and memory disturbance, and epileptic ?ts. Rabies is always fatal and the changes found in patients with AIDS are almost always progressive. Except in very speci?c circumstances, it is not possible to be immunised against encephalitis.
Encephalitis lethargica is one, now rare, variety that reached epidemic levels after World War I. It was characterised by drowsiness and headache leading on to COMA. The disease occasionally occurs as a complication after mumps and sometimes affected individuals subsequently develop postencephalitic PARKINSONISM.... encephalitis
A drug used in the treatment of PARKINSONISM.... orphenadrine
Also known as pallidectomy, this is a neurosurgical procedure in which the activities of the globus pallidus area of the BRAIN are destroyed or modi?ed. The operation is sometimes used to relieve the symptoms of PARKINSONISM and other neurological conditions in which involuntary movements are a signi?cant and disabling symptom.... pallidotomy
Sti?ness, resistance to movement. The term is often used in NEUROLOGY – for example, limb rigidity is a sign of PARKINSONISM. Smooth rigidity is described as being ‘plastic’ and jerky rigidity as ‘cogwheel’.... rigidity
A monoamine-oxidase-B-inhibiting drug used in conjunction with LEVODOPA to treat severe PARKINSONISM. Early treatment with selegiline may delay the need to give the patient levo-dopa, but at present there is no ?rm evidence that it slows down the progression of the disease.... selegiline
A widely prescribed antipsychotic drug used to relieve symptoms of major psychotic illnesses such as schizophrenia and mania. The drug reduces delusional and hallucinatory experiences and may have an effect on irritability and overactivity. It is also used as an antiemetic. Chlorpromazine may cause photosensitivity of the skin and, in some cases, parkinsonism, slow reactions, and blurred vision.... chlorpromazine
A ?ne involuntary movement. Tremors may be seen in projecting parts like the hands, head and tongue, or they may involve muscles. Coarse tremors, which prevent a person from drinking a glass of water without spilling it, are found in MULTIPLE SCLEROSIS (MS) and in CHOREA; somewhat ?ner tremors, which produce trembling of the hands or tongue when they are stretched out, are caused by alcoholism (see ALCOHOL) and other forms of poisoning, by PARKINSONISM, and by the weakness which follows some acute disease or characterises old age. A ?ne tremor of the outstretched ?ngers is a characteristic of thyrotoxicosis (see under THYROID GLAND, DISEASES OF); very ?ne tremors, visible in the muscles of face or limbs and known as ?brillary tremors, are present in general paralysis of the insane (see SYPHILIS), and in progressive muscular atrophy or wasting palsy. Tremors may occur at rest and disappear on movement as in Parkinsonism, or they may occur only on movement (intention tremors) as in cerebellar disease.... tremor
A drug used to treat certain virus infections which is also of value in the prevention of some forms of in?uenza. It is also used to treat PARKINSONISM.... amantadine
A pharmacological e?ect where the action of ACETYLCHOLINE, a chemical neurotransmitter released at the junctions (synapses) of parasympathetic and ganglionic nerves, is inhibited. The junctions between nerves and skeletal muscles have nicotinic receptors. A wide range of drugs with antimuscarinic effects are in use for various disorders including PSYCHOSIS, BRONCHOSPASM, disorders of the eye (see EYE, DISORDERS OF), PARKINSONISM, and problems of the GASTROINTESTINAL TRACT and URINARY TRACT. (See also ANTISPASMODICS.)... antimuscarine
Lindl.
Synonym: A. belladonna auct. non L.
Family: Solanaceae.
Habitat: Kashmir and Himachal Pradesh up to 2,500 m.
English: Indian Belladonna, Indian Atropa.
Ayurvedic: Suuchi.
Unani: Luffaah, Luffaah-Barri, Yabaruj, Shaabiraj.
Action: Highly poisonous; sedative, narcotic, anodyne, nervine, antispasmodic (used in paralysis); parkinsonism; encephalitis; carcinoma; spastic dysmenorrhoea; whooping cough, spasmodic asthma; colic of intestines, gall bladder or kidney, spasm of bladder and ureters; contraindicated in enlarged prostate.
Key application: In spasm and colic-like pain in the areas of the gastrointestinal tract and bile ducts. (German Commission E, The British Herbal Pharmacopoeia.) It is contraindicated in tachycardiac arrhythmias, prostate adenoma, glaucoma, acute oedema of lungs.A. belladonna L. (European sp. Belladonna, Deadly Nightshade) is cultivated in Kashmir and Himachal Pradesh.The herb contains tropane (tropine) or solanaceous alkaloids (up to 0.6%), including hyoscamine and atropine; flavonoids; coumarins; volatile bases (nicotine).Tropane alkaloids inhibit the para- sympathetic nervous system, which controls involuntary bodily activities; reduces saliva, gastric, intestinal and bronchial secretions, and also the activity of urinary tubules. Tropane alkaloids also increase the heart rate and dilate the pupils. These alkaloids are used as an additive to compound formulations for bronchitis, asthma, whooping cough, gastrointestinal hy- permotility, dysmenorrhoea, nocturnal enuresis and fatigue syndrome.Atropine provides relief in parkin- sonism and neurovegetative dystonia.The root is the most poisonous, the leaves and flowers less, and the berries the least. (Francis Brinker.)
Dosage: Leaf, root—30-60 mg powder. (CCRAS.)... atropa acuminata royle ex
This is a colourless, odourless, tasteless, nonirritating gas formed on incomplete combustion of organic fuels. Exposure to CO is frequently due to defective gas, oil or solid-fuel heating appliances. CO is a component of car exhaust fumes and deliberate exposure to these is a common method of suicide. Victims of ?res often suffer from CO poisoning. CO combines reversibly with oxygen-carrying sites of HAEMOGLOBIN (Hb) molecules with an a?nity 200 to 300 times greater than oxygen itself. The carboxyhaemoglobin (COHb) formed becomes unavailable for oxygen transportation. In addition the partial saturation of the Hb molecule results in tighter oxygen binding, impairing delivery to the tissues. CO also binds to MYOGLOBIN and respiratory cytochrome enzymes. Exposure to CO at levels of 500 parts per million (ppm) would be expected to cause mild symptoms only and exposure to levels of 4,000 ppm would be rapidly fatal.
Each year around 50 people in the United Kingdom are reported as dying from carbon monoxide poisoning, and experts have suggested that as many as 25,000 people a year are exposed to its effects within the home, but most cases are unrecognised, unreported and untreated, even though victims may suffer from long-term effects. This is regrettable, given that Napoleon’s surgeon, Larrey, recognised in the 18th century that soldiers were being poisoned by carbon monoxide when billeted in huts heated by woodburning stoves. In the USA it is estimated that 40,000 people a year attend emergency departments suffering from carbon monoxide poisoning. So prevention is clearly an important element in dealing with what is sometimes termed the ‘silent killer’. Safer designs of houses and heating systems, as well as wider public education on the dangers of carbon monoxide and its sources, are important.
Clinical effects of acute exposure resemble those of atmospheric HYPOXIA. Tissues and organs with high oxygen consumption are affected to a great extent. Common effects include headaches, weakness, fatigue, ?ushing, nausea, vomiting, irritability, dizziness, drowsiness, disorientation, incoordination, visual disturbances, TACHYCARDIA and HYPERVENTILATION. In severe cases drowsiness may progress rapidly to COMA. There may also be metabolic ACIDOSIS, HYPOKALAEMIA, CONVULSIONS, HYPOTENSION, respiratory depression, ECG changes and cardiovascular collapse. Cerebral OEDEMA is common and will lead to severe brain damage and focal neurological signs. Signi?cant abnormalities on physical examination include impaired short-term memory, abnormal Rhomberg’s test (standing unsupported with eyes closed) and unsteadiness of gait including heel-toe walking. Any one of these signs would classify the episode as severe. Victims’ skin may be coloured pink, though this is very rarely seen even in severe incidents. The venous blood may look ‘arterial’. Patients recovering from acute CO poisoning may suffer neurological sequelae including TREMOR, personality changes, memory impairment, visual loss, inability to concentrate and PARKINSONISM. Chronic low-level exposures may result in nausea, fatigue, headache, confusion, VOMITING, DIARRHOEA, abdominal pain and general malaise. They are often misdiagnosed as in?uenza or food poisoning.
First-aid treatment is to remove the victim from the source of exposure, ensure an e?ective airway and give 100-per-cent oxygen by tight-?tting mask. In hospital, management is largely suppportive, with oxygen administration. A blood sample for COHb level determination should be taken as soon as practicable and, if possible, before oxygen is given. Ideally, oxygen therapy should continue until the COHb level falls below 5 per cent. Patients with any history of unconsciousness, a COHb level greater than 20 per cent on arrival, any neurological signs, any cardiac arrhythmias or anyone who is pregnant should be referred for an expert opinion about possible treatment with hyperbaric oxygen, though this remains a controversial therapy. Hyperbaric oxygen therapy shortens the half-life of COHb, increases plasma oxygen transport and reverses the clinical effects resulting from acute exposures. Carbon monoxide is also an environmental poison and a component of cigarette smoke. Normal body COHb levels due to ENDOGENOUS CO production are 0.4 to
0.7 per cent. Non-smokers in urban areas may have level of 1–2 per cent as a result of environmental exposure. Smokers may have a COHb level of 5 to 6 per cent.... carbon monoxide (co)
A procedure in which cells – for example, from the pancreas – are taken from an aborted FETUS and then transplanted into the malfunctioning organ (pancreas) of an individual with a disorder of that organ (in this case, diabetes). The cells from the fetus are intended to take over the function of the host’s diseased or damaged cells. Fetal brain cells have also been transplanted into brains of people suffering from PARKINSONISM. These treatments are at an experimental stage.... fetal transplant
These consist either of expanding masses (lumps or tumours), or of areas of shrinkage (atrophy) due to degeneration, or to loss of blood supply, usually from blockage of an artery.
Tumours All masses cause varying combinations of headache and vomiting – symptoms of raised pressure within the inexpansible bony box formed by the skull; general or localised epileptic ?ts; weakness of limbs or disordered speech; and varied mental changes. Tumours may be primary, arising in the brain, or secondary deposits from tumours arising in the lung, breast or other organs. Some brain tumours are benign and curable by surgery: examples include meningiomas and pituitary tumours. The symptoms depend on the size and situation of the mass. Abscesses or blood clots (see HAEMATOMA) on the surface or within the brain may resemble tumours; some are removable. Gliomas ( see GLIOMA) are primary malignant tumours arising in the glial tissue (see GLIA) which despite surgery, chemotherapy and radiotherapy usually have a bad prognosis, though some astrocytomas and oligodendronogliomas are of low-grade malignancy. A promising line of research in the US (in the animal-testing stage in 2000) suggests that the ability of stem cells from normal brain tissue to ‘home in’ on gliomal cells can be turned to advantage. The stem cells were chemically manipulated to carry a poisonous compound (5-?uorouracil) to the gliomal cells and kill them, without damaging normal cells. Around 80 per cent of the cancerous cells in the experiments were destroyed in this way.
Clinical examination and brain scanning (CT, or COMPUTED TOMOGRAPHY; magnetic resonance imaging (MRI) and functional MRI) are safe, accurate methods of demonstrating the tumour, its size, position and treatability.
Strokes When a blood vessel, usually an artery, is blocked by a clot, thrombus or embolism, the local area of the brain fed by that artery is damaged (see STROKE). The resulting infarct (softening) causes a stroke. The cells die and a patch of brain tissue shrinks. The obstruction in the blood vessel may be in a small artery in the brain, or in a larger artery in the neck. Aspirin and other anti-clotting drugs reduce recurrent attacks, and a small number of people bene?t if a narrowed neck artery is cleaned out by an operation – endarterectomy. Similar symptoms develop abruptly if a blood vessel bursts, causing a cerebral haemorrhage. The symptoms of a stroke are sudden weakness or paralysis of the arm and leg of the opposite side to the damaged area of brain (HEMIPARESIS), and sometimes loss of half of the ?eld of vision to one side (HEMIANOPIA). The speech area is in the left side of the brain controlling language in right-handed people. In 60 per cent of lefthanders the speech area is on the left side, and in 40 per cent on the right side. If the speech area is damaged, diffculties both in understanding words, and in saying them, develops (see DYSPHASIA).
Degenerations (atrophy) For reasons often unknown, various groups of nerve cells degenerate prematurely. The illness resulting is determined by which groups of nerve cells are affected. If those in the deep basal ganglia are affected, a movement disorder occurs, such as Parkinson’s disease, hereditary Huntington’s chorea, or, in children with birth defects of the brain, athetosis and dystonias. Modern drugs, such as DOPAMINE drugs in PARKINSONISM, and other treatments can improve the symptoms and reduce the disabilities of some of these diseases.
Drugs and injury Alcohol in excess, the abuse of many sedative drugs and arti?cial brain stimulants – such as cocaine, LSD and heroin (see DEPENDENCE) – can damage the brain; the effects can be reversible in early cases. Severe head injury can cause localised or di?use brain damage (see HEAD INJURY).
Cerebral palsy Damage to the brain in children can occur in the uterus during pregnancy, or can result from rare hereditary and genetic diseases, or can occur during labour and delivery. Severe neurological illness in the early months of life can also cause this condition in which sti? spastic limbs, movement disorders and speech defects are common. Some of these children are learning-disabled.
Dementias In older people a di?use loss of cells, mainly at the front of the brain, causes ALZHEIMER’S DISEASE – the main feature being loss of memory, attention and reasoned judgement (dementia). This affects about 5 per cent of the over-80s, but is not simply due to ageing processes. Most patients require routine tests and brain scanning to indicate other, treatable causes of dementia.
Response to current treatments is poor, but promising lines of treatment are under development. Like Parkinsonism, Alzheimer’s disease progresses slowly over many years. It is uncommon for these diseases to run in families. Multiple strokes can cause dementia, as can some organic disorders such as cirrhosis of the liver.
Infections in the brain are uncommon. Viruses such as measles, mumps, herpes, human immunode?ciency virus and enteroviruses may cause ENCEPHALITIS – a di?use in?ammation (see also AIDS/HIV).
Bacteria or viruses may infect the membrane covering the brain, causing MENINGITIS. Viral meningitis is normally a mild, self-limiting infection lasting only a few days; however, bacterial meningitis – caused by meningococcal groups B and C, pneumococcus, and (now rarely) haemophilus – is a life-threatening condition. Antibiotics have allowed a cure or good control of symptoms in most cases of meningitis, but early diagnosis is essential. Severe headaches, fever, vomiting and increasing sleepiness are the principal symptoms which demand urgent advice from the doctor, and usually admission to hospital. Group B meningococcus is the commonest of the bacterial infections, but Group C causes more deaths. A vaccine against the latter has been developed and has reduced the incidence of cases by 75 per cent.
If infection spreads from an unusually serious sinusitis or from a chronically infected middle ear, or from a penetrating injury of the skull, an abscess may slowly develop. Brain abscesses cause insidious drowsiness, headaches, and at a late stage, weakness of the limbs or loss of speech; a high temperature is seldom present. Early diagnosis, con?rmed by brain scanning, is followed by antibiotics and surgery in hospital, but the outcome is good in only half of affected patients.
Cerebral oedema Swelling of the brain can occur after injury, due to engorgement of blood vessels or an increase in the volume of the extravascular brain tissue due to abnormal uptake of water by the damaged grey (neurons) matter and white (nerve ?bres) matter. This latter phenomenon is called cerebral oedema and can seriously affect the functioning of the brain. It is a particularly dangerous complication following injury because sometimes an unconscious person whose brain is damaged may seem to be recovering after a few hours, only to have a major relapse. This may be the result of a slow haemorrhage from damaged blood vessels raising intracranial pressure, or because of oedema of the brain tissue in the area surrounding the injury. Such a development is potentially lethal and requires urgent specialist treatment to alleviate the rising intracranial pressure: osmotic agents (see OSMOSIS) such as mannitol or frusemide are given intravenously to remove the excess water from the brain and to lower intracranial pressure, buying time for de?nitive investigation of the cranial damage.... brain, diseases of
A condition in which a person infrequently passes hard FAECES (stools). Patients sometimes complain of straining, a feeling of incomplete evacuation of faeces, and abdominal or perianal discomfort. A healthy individual usually opens his or her bowels once daily but the frequency may vary, perhaps twice daily or once only every two or three days. Constipation is generally de?ned as fewer than three bowel openings a week. Healthy people may have occasional bouts of constipation, usually re?ecting a temporary change in diet or the result of taking drugs – for example, CODEINE – or any serious condition resulting in immobility, especially in elderly people.
Constipation is a chronic condition and must be distinguished from the potentially serious disorder, acute obstruction, which may have several causes (see under INTESTINE, DISEASES OF). There are several possible causes of constipation; those due to gastrointestinal disorders include:
Dietary: lack of ?bre; low ?uid consumption.
Structural: benign strictures (narrowing of gut); carcinoma of the COLON; DIVERTICULAR DISEASE.
Motility: poor bowel training when young; slow transit due to reduced muscle activity in the colon, occurring usually in women; IRRITABLE BOWEL SYNDROME (IBS); HIRSCHSPRUNG’S DISEASE.
•Defaecation: anorectal disease such as ?ssures, HAEMORRHOIDS and CROHN’S DISEASE; impaction of faeces. Non-gastrointestinal disorders causing constipation include:
Drugs: opiates (preparations of OPIUM), iron supplements, ANTACIDS containing aluminium, ANTICHOLINERGIC drugs.
Metabolic and endocrine: DIABETES MELLITUS, pregnancy (see PREGNANCY AND LABOUR), hypothyroidism (see under THYROID GLAND, DISEASES OF).
Neurological: cerebrovascular accidents (STROKE), MULTIPLE SCLEROSIS (MS), PARKINSONISM, lesions in the SPINAL CORD. Persistent constipation for which there is no
obvious cause merits thorough investigation, and people who experience a change in bowel habits – for example, alternating constipation and diarrhoea – should also seek expert advice.
Treatment Most people with constipation will respond to a dietary supplement of ?bre, coupled, when appropriate, with an increase in ?uid intake. If this fails to work, judicious use of LAXATIVES for, say, a month is justi?ed. Should constipation persist, investigations on the advice of a general practitioner will probably be needed; any further treatment will depend on the outcome of the investigations in which a specialist will usually be involved. Successful treatment of the cause should then return the patient’s bowel habits to normal.... constipation
A device that covers the nose and mouth to enable inhalation anaesthetics (see ANAESTHESIA) or other gases such as oxygen to be administered. It is also a covering for the nose and mouth to ensure that antiseptic conditions are maintained during surgery, when dressing a wound or nursing a patient in conditions of isolation. The term is also applied to the expressionless appearance that occurs in certain disorders – for example, in PARKINSONISM.... mask
See PARKINSONISM.... paralysis agitans
The way in which an individual walks. Gait may be affected by inherited disorders; by illness – especially neurological disorders; by injury; or by drug and alcohol abuse. Children, as a rule, begin to walk between the ages of 12 and 18 months, having learned to stand before the end of the ?rst year. If a normal-sized child shows no ability to make movements by this time, the possibility of mental retardation must be borne in mind, and if the power of walking is not gained by the time the child is a year and a half old, RICKETS, CEREBRAL PALSY, or a malformation of the hip-joint must be excluded.
In hemiplegia, or PARALYSIS down one side of the body following a STROKE, the person drags the paralysed leg.
Steppage gait occurs in certain cases of alcoholic NEURITIS, tertiary SYPHILIS (tabes) and other conditions where the muscles that raise the foot are weak so that the toes droop. The person bends the knee and lifts the foot high, so that the toes may clear obstacles on the ground. (See DROP-FOOT.)
In LOCOMOTOR ATAXIA or tabes dorsalis, the sensations derived from the lower limbs are blunted, and consequently the movements of the legs are uncertain and the heels planted upon the ground with unnecessary force. When the person tries to turn or stands with the eyes shut, he or she may fall over. When they walk, they feel for the ground with a stick or keep their eyes constantly ?xed upon it.
In spastic paralysis the limbs are moved with jerks. The foot ?rst of all clings to the ground and then leaves it with a spasmodic movement, being raised much higher than is necessary.
In PARKINSONISM the movements are tremulous, and as the person takes very short steps, he or she has the peculiarity of appearing constantly to fall forwards, or to be chasing themselves.
In CHOREA the walk is bizarre and jerky, the affected child often seeming to leave one leg a step behind, and then, with a screwing movement on the other heel, go on again.
Psychologically based idiosyncracies of gait are usually of a striking nature, quite di?erent from those occuring in any neurological conditions. They tend to draw attention to the patient, and are worse when he or she is observed.... gait
Soursop (Annona muricata).Plant Part Used: Leaf, fruit.Dominican Medicinal Uses: Leaf: tea, orally, for common cold, flu, musculoskeletal injury, menopausal symptoms, nervousness/anxiety; externally as a bath for fever in children. Fruit: eaten, diuretic and fever-reducing.Safety: Fruits are commonly consumed; reports of toxicity from ingestion of leaves in humans; contradictory results from animal toxicity studies; possibly implicated in atypical parkinsonism in the Caribbean.Laboratory & Preclinical Data: In vivo: antioxidant (stem bark alcohol extract).In vitro: human serotonin receptor binding activity, antiviral (HSV-1), cytotoxic in cancer cells, molluscicidal in schistosomiasis vector (plant extracts and constituents).* See entry for Guanábana in “Part 3: Dominican Medicinal Plant Profiles” of this book for more information, including references.... guanábana
These drugs produce partial or complete paralysis of skeletal muscle (see under MUSCLE – Structure of muscle). Drugs in clinical use are all reversible and are used to help insert a breathing tube into the TRACHEA (endotracheal tube) during general ANAESTHESIA and ARTIFICIAL VENTILATION OF THE LUNGS. They may be broadly divided into depolarising and nondepolarising muscle relaxants. Depolarising muscle relaxants act by binding to acetylcholine receptors at the motor end-plate where nerves are attached to muscle cells, and producing a more prolonged depolarisation than acetylcholine, which results in initial muscle fasciculation (overactivity) and then ?accid paralysis of the muscle. The only commonly used depolarising drug is succinylcholine which has a rapid onset of action and lasts approximately three minutes. Non-depolarising muscle relaxants bind to the acetylcholine receptors, preventing acetylcholine from gaining access to them. They have a slower onset time and longer duration than depolarisers, although this varies widely between di?erent drugs. They are competitive antagonists and they may be reversed by increasing the concentration of acetylcholine at the motor end-plate using an anticholinesterase agent such as neostigmine. These drugs are broken down in the liver and excreted through the kidney, and their action will be prolonged in liver and renal failure. Other uses include the relief of skeletal muscle spasms in TETANUS, PARKINSONISM and spastic disorders. The drugs dantrolene and diazepam are used in these circumstances.... muscle relaxants
Also called ptyalism, this is the excessive production of SALIVA. It occurs in various nervous disorders, such as PARKINSONISM; poisoning by MERCURY or mushrooms; or RABIES infection.... sialorrhoea
Paralysis, or PALSY, is loss of muscular power due to some disorder of the NERVOUS SYSTEM. Weakness – rather than total movement loss – is sometimes described as paresis. Paralysis may be temporary or permanent and may be accompanied by loss of feeling.
Paralysis due to brain disease The most common form is unilateral palsy, or HEMIPLEGIA, generally arising from cerebral HAEMORRHAGE, THROMBOSIS or EMBOLISM affecting the opposite side of the BRAIN. If all four limbs and trunk are affected, the paralysis is called quadraplegia; if both legs and part of the trunk are affected, it is called paraplegia. Paralysis may also be divided into ?accid (?oppy limbs) or spastic (rigid).
In hemiplegia the cause may be an abscess, haemorrhage, thrombosis or TUMOUR in the brain. CEREBRAL PALSY or ENCEPHALITIS are other possible causes. Sometimes damage occurs in the parts of the nervous system responsible for the ?ne control of muscle movements: the cerebellum and basal ganglion are such areas, and lack of DOPAMINE in the latter causes PARKINSONISM.
Damage or injury Damage to or pressure on the SPINAL CORD may paralyse muscles supplied by nerves below the site of damage. A fractured spine or pressure from a tumour may have this e?ect. Disorders affecting the cord which can cause paralysis include osteoarthritis of the cervical vertebrae (see BONE, DISORDERS OF), MULTIPLE SCLEROSIS (MS), MYELITIS, POLIOMYELITIS and MENINGITIS. Vitamin B12 de?ciency (see APPENDIX 5: VITAMINS) may also cause deterioration in the spinal cord (see also SPINE AND SPINAL CORD, DISEASES AND INJURIES OF).
Neuropathies are a group of disorders, some inherited, that damage the peripheral nerves, thus affecting their ability to conduct electrical impulses. This, in turn, causes muscle weakness or paralysis. Among the causes of neuropathies are cancers, DIABETES MELLITUS, liver disease, and the toxic consequences of some drugs or metals – lead being one example.
Disorders of the muscles themselves – for example, muscular dystrophy (see MUSCLES, DISORDERS OF – Myopathy) – can disturb their normal working and so cause partial or complete paralysis of the part(s) affected.
Treatment The aim of treatment should be to remedy the underlying cause – for example, surgical removal of a displaced intervertebral
disc or treating diabetes mellitus. Sometimes the cause cannot be recti?ed but, whether treatable or not, physiotherapy is essential to prevent joints from seizing up and to try to maintain some tone in muscles that may be only partly affected. With temporary paralysis, such as can occur after a STROKE, physiotherapy can retrain the sufferers to use their muscles and joints to ensure mobility during and after recovery. Patients with permanent hemiplegia, paraplegia or quadraplegia need highly skilled nursing care, rehabilitative support and resources, and expert help to allow them, if possible, to live at home.... paralysis
Professionally trained speech therapists assist, diagnose and treat the whole spectrum of acquired or developmental communication disorders. They work in medical and education establishments, often in an advisory or consultative capacity. The medical conditions in which speech therapy is employed include: dysgraphia, DYSLEXIA, DYSARTHRIA, DYSPHASIA, DYSPHONIA, DYSPRAXIA, AUTISM, BELL’S PALSY, CEREBRAL PALSY, DEAFNESS, disordered language, delayed speech, disordered speech, DOWN’S (DOWN) SYNDROME, LARYNGECTOMY, LEARNING DISABILITY, MACROGLOSSIA, MOTOR NEURONE DISEASE (MND), malformations of the PALATE, PARKINSONISM, STAMMERING, STROKE and disorders of voice production.
Speech therapists form a small independent profession, most of whom work for the National Health Service in community clinics, general practices and hospitals. They may also work in schools or in units for the handicapped, paediatric assessment centres, language units attached to primary schools, adult training centres and day centres for the elderly.
A speech therapist undergoes a four-year degree course which covers the study of disorders of communication in children and adults, phonetics and linguistics, anatomy and physiology, psychology and many other related subjects. Further information on training can be obtained from the College of Speech Therapists.
If the parents of a child are concerned about their child’s speech, they may approach a speech therapist for assessment and guidance. Their general practitioner will be able to give them local addresses or they should contact the district speech therapist. Adults are usually referred by hospital consultants.
The College of Speech Therapists keeps a register of all those who have passed a recognised degree or equivalent quali?cation in speech therapy. It will be able to direct you to your nearest NHS or private speech therapist.... speech therapy
Abnormal muscular movements. Uncontrollable twitching, jerking, or writhing movements cannot be suppressed and may affect control of voluntary movements. The disorder may involve the whole body or be restricted to a group of muscles. Types of dyskinesia include chorea (jerking movements), athetosis (writhing), choreoathetosis (a combined form), myoclonus (muscle spasms), tics (repetitive fidgets), and tremors. Dyskinesia may result from brain damage at birth or may be a side effect of certain drugs (see tardive dyskinesia), which often disappears when the drug is stopped. Otherwise, dyskinesia is difficult to treat. (See also parkinsonism.)... dyskinesia
Deadly nightshade. Atropa belladonna L. German: Amaryllis. French: Belladonne d’Automne. Spanish: Belladonna. Italian: Amarilli a fiori rosei. Indian: Suchi.
Action. Antispasmodic, antasthmatic, anti-sweat, sedative, lactifuge.
For use by qualified practitioner only.
Uses: Spasmodic asthma; colic of intestines, gall bladder or kidney; spasm of bladder and ureters. Whooping cough, excessive perspiration (night sweats, etc), spermatorrhoea, bed-wetting (dose afternoon and at bedtime), dribbling of saliva in Parkinsonism. The common cold, hay fever, acidity – to inhibit secretion of stomach acid.
Contra-indications. Glaucoma, rapid heart, pregnancy, enlarged prostate. Side-effects – dry mouth, dilated pupils, mental disorientation. Used for a millennia in China as an anaesthetic (Kiangsu – 1719)
Widely used in homoeopathic medicine.
Preparations: Unless otherwise prescribed – up to thrice daily. Dried herb, 50mg in infusion. Tincture, BHC (vol 1). 1:10, 70 per cent ethanol, 0.5ml.
Initial dose recommended per week by British Herbal Compendium, Vol 1; dried leaf, 200mg (max 1g); tincture, 2ml (max 10ml).
A weaker solution may sometimes be used with good effect: 5 drops tincture to 100ml water – 1 teaspoon hourly. (Dr Finlay Ellingwood)
Pharmacy only sale ... belladonna
St John’s Wort. Hypericum perforatum L. German: Tupfelharthen. French: Mille pertuis. Spanish: Hierba de San Juan. Italian: Perforata. Iranian: Dadi. Arabian: Hynfarikun. Chinese: Chin-ssu?- t’sao. Leaves and flowers. Keynote: pain.
Constituents: flavonoids, hypericins, essential oil.
Action: alterative, astringent, antiviral, relaxing nervine, anti-depressant, sedative, anti-inflammatory, cardio-tonic. Analgesic (external).
Topical. Antiseptic, analgesic (mild). To promote coronary flow and strengthen the heart.
Uses: Neuralgia (facial and intercostal), sciatica, concussion of the spine, post-operative pain and neuralgia, physical shock. Pain in coccyx, polymyalgia with tingling of fingers or feet, to reduce pain of dental extractions. Injuries to flesh rich in nerves – finger tips or sole of feet. Shooting, stitching pains. Punctured wounds: bites of dogs (rabies), cats, rats where pain shoots up the arm from the wound. Painful piles. Chorea. Tetanus. Temporary relief reported in Parkinsonism. Has been used with some success in relieving cramps of terminal disease. Anxiety, stress, depression. Menopausal nervousness. Menstrual cramps.
Researchers have shown that the herb possesses radioprotective properties. (Biol. Nauki. 1992 (4) 709)
Preparations: Average dose: 2-4 grams, or equivalent in fluid form. Thrice daily. Tea: 1 heaped teaspoon to each cup of boiling water; infuse 15 minutes. Half a cup. Liquid Extract: 15-60 drops in water.
Tincture BHP (1983). 1:10 in 45 per cent alcohol. Dose: 2-4ml.
Flowers: steeped in Olive oil offer a good dressing for burns, sores and stubborn ulcers. Oil of St John’s Wort, (topical).
Compress, or wet pack for wounds or rheumatism: tea rinse.
Keynote: depression ... hypericum
A term that is used to indicate the number of pregnancies a womanhas undergone that have resulted in the birth of a baby capable of survival. parkinsonism Any neurological disorder characterized by a mask-like face, rigidity, and slow movements. The most common type is Parkinson’s disease.
Parkinson’s disease A neurological disorder that causes muscle tremor, stiffness, and weakness. The characteristic signs are trembling, rigid posture, slow movements, and a shuffling, unbalanced walk. The disease is caused by degeneration of, or damage to, cells in the basal ganglia of the brain, reducing the amount of dopamine (which is needed for control of movement). It occurs mainly in elderly people and is more common in men.
The disease usually begins as a slight tremor of 1 hand, arm, or leg, which is worse when the hand or limb is at rest. Later, both sides of the body are affected, causing a stiff, shuffling, walk; constant trembling of the hands, sometimes accompanied by shaking of the head; a permanent rigid stoop; and an unblinking, fixed expression. The intellect is unaffected until late in the disease.
There is no cure.
Drug treatment is used to minimize symptoms in later stages.
Levodopa, which the body converts into dopamine, is usually the most effective drug.
It may be used in combination with benserazide or carbidopa.
The effects of levodopa gradually wear off.
Drugs that may be used in conjunction with it, or as substitutes for it, include amantadine and bromocriptine.
Surgical operations on the brain are occasionally performed.
Untreated, the disease progresses over 10 to 15 years, leading to severe weakness and incapacity.
About one third of sufferers eventually develop dementia.... parity
A rare degenerative disorder of unknown cause that progressively damages the autonomic nervous system. It begins gradually at age 60–70 and is more common in men. Symptoms include dizziness and fainting due to postural hypotension, urinary incontinence, impotence, reduced ability to sweat, and parkinsonism. The condition eventually leads to disability, and sometimes premature death. There is no cure or means of slowing degeneration, but many symptoms are relieved by drugs.... shy–drager syndrome
Abnormal, uncontrolled movements, mainly of the face, tongue, mouth, and neck. Tardive dyskinesia may be caused by prolonged use of antipsychotic drugs, and is distinct from parkinsonism.... tardive dyskinesia
several large masses of grey matter embedded deep within the white matter of the *cerebrum (see illustration). They include the caudate and lenticular nuclei (together known as the corpus striatum) and the amygdaloid nucleus. The lenticular nucleus consists of the putamen and globus pallidus. The basal ganglia have complex neural connections with both the cerebral cortex and thalamus: they are involved with the regulation of voluntary movements at a subconscious level. Diseases of the basal ganglia cause a range of disorders predominantly affecting movement, the commonest being *parkinsonism.... basal ganglia
n. a symptom of *parkinsonism comprising a difficulty in initiating movements and slowness in executing movements.... bradykinesia
n. a *dopamine receptor agonist, derived from ergot, that is used in the treatment of disorders associated with excessive secretion of *prolactin (such as *prolactinoma and galactorrhoea), since it inhibits the secretion of this hormone by the pituitary gland. It may also be used to treat *acromegaly, as it suppresses the release of growth hormone, and – rarely – parkinsonism. Side-effects may include nausea, constipation, drowsiness, and dizziness, and there is a risk of *fibrosis.... bromocriptine
(anticholinergic) adj. inhibiting the action of *acetylcholine, the neurotransmitter that conveys information in the parasympathetic nervous system. Antimuscarinic drugs block the effects of certain (muscarinic) receptors (hence their name). The actions of these drugs include relaxation of smooth muscle, decreased secretion of saliva, sweat, and digestive juices, and dilation of the pupil of the eye. *Atropine and similar drugs have these effects; they are used in the treatment of gut spasms (e.g. *propantheline) and of parkinsonism (e.g. *trihexyphenidyl) as bronchodilators (e.g. *ipratropium), and as *mydriatics. Characteristic side-effects include dry mouth, thirst, blurred vision, dry skin, increased heart rate, and difficulty in urination.... antimuscarinic
a disorder characterized by a combination of *parkinsonism and *dementia, which typically fluctuates. Visual hallucinations are common, and there is exquisite sensitivity to phenothiazine drugs. Abnormal proteins called Lewy bodies are found within the nerve cells of the cortex and the basal ganglia. It is the third most common cause of dementia (dementia with Lewy bodies) after *Alzheimer’s disease and vascular dementia.... cortical lewy body disease
symptoms caused by a reduction of dopamine activity in the extrapyramidal system due to the adverse effects of *dopamine receptor antagonists, notably phenothiazine *antipsychotic drugs. These effects include *parkinsonism, *akathisia, and *dyskinesia.... extrapyramidal effects
n. a greyish metallic element, the oxide of which, when inhaled by miners in underventilated mines, causes brain damage and symptoms very similar to those of *parkinsonism. Minute quantities of the element are required by the body (see trace element). Symbol: Mn.... manganese
(MSA) a condition that results from degeneration of cells in the *basal ganglia (resulting in *parkinsonism), the *cerebellum (resulting in *ataxia), the *pyramidal system, and the *autonomic nervous system (resulting in symptoms of autonomic failure, such as postural hypotension).... multiple system atrophy
an agent that reduces tension in voluntary muscles. Drugs such as *baclofen, *dantrolene, and *diazepam are used to relieve skeletal muscular spasms in various spastic conditions, parkinsonism, and tetanus. The drugs used to relax voluntary muscles during the administration of anaesthetics in surgical operations act by blocking the transmission of impulses at neuromuscular junctions. Nondepolarizing muscle relaxants, e.g. *atracurium besilate, cisatracurium, pancuronium, and rocuronium, bind to receptor sites normally occupied by acetylcholine; depolarizing muscle relaxants, e.g. *suxamethonium, mimic the action of acetylcholine but *depolarization is prolonged.... muscle relaxant
n. an *antimuscarinic drug used to reduce muscle tremor and rigidity in parkinsonism. Common side-effects include dry mouth, blurred vision, and giddiness.... procyclidine
(Steele–Richardson–Olszewski syndrome) a progressive neurological disorder resulting from degeneration of the motor neurons, basal ganglia, and brainstem. Starting in late middle age, it is characterized by a staring facial expression due to impaired ability to move the eyes up and down, progressing to difficulties in swallowing, speech, balance, and movement and general spasticity. The condition enters the differential diagnosis of *parkinsonism, with which it is often confused in its early stages.... progressive supranuclear palsy
a group of symptoms consisting of progressive *dementia, tremor of the hands, epilepsy, and parkinsonism. It is a consequence of repeated blows to the head that have been severe enough to cause *concussion.... punch-drunk syndrome
n. a compulsive tendency to walk backwards. It is a symptom of *parkinsonism.... retropulsion
an archaic name for Parkinson’s disease (see parkinsonism).... shaking palsy
n. a rhythmical nodding movement of the head, sometimes involving the trunk. It is seen in patients with *parkinsonism and cerebellar disorders. Occasionally the use of this term is extended to include a stumbling gait.... titubation
(benzhexol) n. an *antimuscarinic drug that is used mainly to reduce muscle tremor and rigidity in drug-induced parkinsonism. The most common side-effects are constipation, dry mouth, and blurred vision.... trihexyphenidyl
an inborn defect of copper metabolism in which there is a deficiency of *caeruloplasmin (which normally forms a nontoxic complex with copper). It is inherited as an autosomal *recessive characteristic. The free copper may be deposited in the liver, causing jaundice and cirrhosis, or in the brain, causing learning disabilities and symptoms resembling *parkinsonism. There is a characteristic brown ring in the cornea (the Kayser–Fleischer ring). If the excess copper is removed from the body by regular treatment with *penicillamine both mental and physical deficits tend to improve. Medical name: hepatolenticular degeneration. [S. A. K. Wilson (1878–1936), British neurologist]... wilson’s disease
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