Tremor

TREMOR (tremor), trembling, involuntary rhythmic muscle contractions causing rhythmic rotational movements of a body part, for example, fingers, hand, head, jaw, etc., around an axis passing through a joint. Tremor is sometimes observed during rest, sometimes only during voluntary movement. The latter type of tremor is called intentional tremor. Usually, more coarse work can be performed with tremor, but finer and more delicate movements are difficult; thus, it is difficult to thread a needle, handwriting deteriorates. Walking sometimes becomes impossible. During sleep, tremor usually ceases. Fatigue, cooling, concentration of attention, muscle tension usually increase tremor. Tremor more often affects the upper extremities, fingers or hands, less often the proximal parts. However, the head, facial muscles, lower jaw, tongue, lower extremities and trunk can also be affected by tremor. Tremor is most common in old age and senility, but can also occur in young age.--Tremor varies in character depending on the frequency and amplitude of oscillations. Fast tremor has 8-12 oscillations per second, medium tremor corresponds to 5-8, slow tremor to 3-5 oscillations per second. The amplitude of tremor does not depend on its frequency. It is either barely visible or perceptible, or conversely in some cases very large, reaching 15 or more centimeters. Tremor can appear in completely healthy individuals after muscle strain, after lifting heavy weights, in connection with emotions of fear, horror, after sexual excesses. Such physiological tremor usually occurs in individuals with nervous predisposition and increased excitability. Such tremor is more common in women and children. Often such physiological tremor is accompanied by sharply expressed vasomotor symptoms, redness or pallor of the face, cardiac arrest or palpitations, disturbed breathing, diarrhea, psychic experiences. In such cases, tremor appears suddenly and passes just as quickly. In other cases, tremor can become fixed. It can become permanent, exacerbating under certain conditions but constantly manifesting when extending the arms or holding an object at arm's length or when lifting heavy weights. Kollarits considers the so-called physiological tremor as a result of insufficient coordination caused by the play of agonists and antagonists necessary for maintaining balance and regulating position. There is no fundamental difference between resting tremor and intentional tremor, since maintaining rest also requires a certain muscular work in which sarcoplasm determining tone plays the most essential role. In connection with this, it is necessary to seek the central nervous correlate of physiological tremor in the striatal and autonomic systems. For studying tremor, special apparatuses for its recording have been constructed, making it possible to record oscillations in three planes. Such a tremograph was proposed by Sommer. Recording action potentials can also provide indications of the nature and mechanism of tremor. Quinquaud proposed to study tremor by placing the spread fingers of the subject at an obtuse angle on the palm of the examiner. In this case, tremor is felt as crepitation or crackling. Quinquaud considered this symptom characteristic of alcoholics, but subsequent authors (L. S. Minor) showed that this phenomenon is also observed in healthy individuals. In general, it is quite sufficient to study tremor with the naked eye. Its features are so obvious in each case that they make it possible to draw appropriate conclusions for diagnosis. A good method for studying tremor is finally the analysis of handwriting, in particular with the help of a magnifying glass. One can also have the patient draw horizontal and vertical lines. This results in a kind of graphic representation of tremor. Tremor occurs in a number of pathological conditions. In functional nervous diseases, in neurasthenia, especially in traumatic neurosis, tremor is an essential part of the neurotic syndrome and the main complaint of patients. It can be generalized or limited to a part of the body. The upper extremities are more often affected. The eyelids, tongue, head often participate, less often the lower extremities. During excitement and affect, it significantly intensifies, sometimes reaching very large sizes in amplitude of oscillations. In some cases, tremor is observed only in the form of attacks and is then characterized by particular amplitude. After war injuries, as well as after concussions of the skull and trunk, a characteristic trembling neurosis develops. It can also develop after severe psychic trauma, severe fatigue during marches, cooling, fatigue. These forms are very close to the tremor of hysterics, in which it also predominantly appears during excitement and affect. Under the influence of suggestion, hysterical tremor can disappear, however, it has a tendency to recur.-A number of nervous system intoxications cause tremor. These particularly include alcohol poisoning. Chronic alcoholics show medium-sized tremor of the hands, which is especially visible when spreading the fingers. Tremor of the tongue and head is observed. In the morning and on an empty stomach it intensifies. Sometimes it decreases and even disappears after eating, as well as after wine. Thus, a vicious circle is formed: unable to work due to tremor, the chronic alcoholic in the morning prefers to drink a glass to get rid of tremor for some time, instead of completely curing tremor and alcoholism through complete and prolonged abstinence. Tremor in acute alcohol poisoning is significantly larger and more generalized. In delirium tremens, shaking of the whole body, facial muscles, tongue, hands, head is observed.--Similar to chronic alcoholism is lead tremor. Mercury tremor of medium frequency and amplitude is usually localized in the facial muscles, tongue, upper extremities. According to some authors, it resembles tremor in progressive paralysis, but it should be borne in mind that progressive paralytics may sometimes also have mercury poisoning.-Among other poisons leading to tremor, morphine, chloral hydrate, caffeine and nicotine should also be mentioned. Also a whole range of other poisonous substances, partly medicinal in nature, such as carbon disulfide, carbon monoxide, iodine, bromine, arsenic, manganese, etc., cause tremor when administered in large doses, especially in predisposed individuals. Among endogenous poisonings leading to tremor, Graves' disease and generally hyperthyroidosis should be mentioned first. Tremor of the hands constitutes one of the most typical symptoms of Graves' disease. Fine, fast tremor is usually localized in the upper extremities. When listening to the lungs, one can sometimes note saccadic breathing (P. Marie, Minor), which is nothing other than vibrations of the respiratory musculature, similar to tremor. Haskovec described in cachexias after thyroidectomy fibrillary twitchings passing into myokymia, and then into fine and fast tremor of the head, extremities and whole body. Toxic tremor of endogenous type includes tremor in uremia, eclampsia and diabetes. In acute and cachectic stages of a number of infectious or chronic diseases, for example, in typhus, other typhoids, malaria, in cancer, tuberculosis, etc., tremor of varying amplitude is encountered, the pathogenesis of which should ultimately also be attributed to endogenous, and partly exogenous intoxications. From organic nervous diseases, tremor is very often found in neuritis and polyneuritis. Such tremor has been partly mentioned above in connection with tremor due to intoxication and infection. Tremor in multiple sclerosis is very characteristic. It has a distinctly intentional character. At rest it is almost absent and sharply increases during movement. As the target is approached, for example, the tip of the nose, it reaches such an amplitude that it completely prevents the task from being performed; thus, in severe cases, the patient is unable to bring a glass of water to his mouth. On the contrary, tremor in paralysis agitans or in parkinsonism after epidemic encephalitis is usually observed at rest and ceases during movement. Its amplitude is medium, in any case parkinsonian tremor is larger and rarer than tremor in Graves' disease. It is usually localized in the distal ends of the upper extremities and here predominantly in the thumb, the movements of which resemble the rolling of pills or the rolling of bread balls. In more severe cases, the tongue and lower jaw also participate in the tremor. During sleep, tremor ceases. Tremor, often with a sharply expressed intentional character, is observed in Strümpell-Westphal pseudosclerosis, in Wilson's disease. Such a broad, large tremor also characterizes hereditary cerebellar ataxia. In combination with alternating paralysis of the oculomotor nerve, tremor sometimes develops on one side of the body, affecting usually to a greater degree or exclusively the upper, to a lesser degree the lower extremity. This Benedict syndrome develops as a result of a vascular focus or due to a tumor in the area of the cerebral peduncle with involvement of the red nucleus in the pathological process.

With general cerebral arteriosclerosis and with progressive paralysis, a very characteristic tremor of small caliber is observed, in which, unlike Parkinson's tremor, the head and speech apparatus, in particular the vocal cords, often participate. In connection with the latter circumstance, speech is extremely difficult. Senile tremor is slow, with a small amplitude, and is predominantly localized in the head, more often in the form of flexion and extension of the head ('yes-tremor'), and less often in the form of small rotational movements in opposite directions around the vertical axis ('no-tremor'). In addition to the head, the lower jaw or one or both upper extremities also sometimes tremble. Familial tremor presents a certain interest in that, according to the research of some authors (Minor), elements of inheritance according to the Mendelian type can be distinguished in it. Minor showed that familial, or hereditary, tremor often combines with longevity and numerous offspring (typus multiparus macrobioticus). Hereditary tremor is distinguished by a small amplitude, slowness, and often combines with physical or mental stigmata of degeneration, in particular with obsessive ideas or compulsive movements (nystagmus, etc.). In the same family, tremor appears at different ages, more often in middle age or even old age. However, in such a 'tremulous family,' tremor often appears at a young age. Pathogenesis. Tremor is a special type of hyperkinesia, which, like most hyperkinesias, is associated with disease of the subcortical nodes. The autonomic nervous system undoubtedly plays an enormous role in its genesis, which in turn is in close anatomical and functional connection with the striatal system, in particular with the black substance of Soemmering. The nature of the disease located in these places can be varied: either vascular, or tumor, or degenerative familial processes of a special nature, as in Wilson's disease, or multiple sclerosis. It can also be a question of toxic effects on these areas. Large tremor most often depends on a disease of the red nucleus. However, tremor undoubtedly also occurs with damage to the peripheral nervous apparatus. Thus, the tremor that occurs in polyneuritis, in some forms of infectious radiculitis, should be explained exclusively as a result of disease of the peripheral vegetative apparatus. In any case, the most important role in the pathogenesis of tremor is played by a change in the function of the tone of striated muscle, which depends less on the cerebrospinal system, in particular the peripheral motor neuron, than on the antagonistic play of the autonomic nervous system. Irritation of the parasympathetic nervous system, for example by physostigmine, or its inhibition due to irritation, for example by adrenaline, its antagonist—the sympathetic nervous system—can cause tremor. In particular, the tremor in Graves' disease, which some consider a sympathicotopic disease, as well as the tremor in vagotonic individuals, are good illustrations of these relationships. The prognosis, of course, depends on the underlying disease. Hereditary tremor in general gives an unfavorable prognosis for recovery. Treatment of tremor basically coincides with the treatment of the disease of which it is a symptom, however, since tremor is often a very distressing symptom affecting the patient's ability to work, it is necessary to resort to palliative treatment of this symptom specifically. Hypnosis, massage, water procedures, electrization are of little effect, although for a time they give some relief. A more substantial effect is obtained in the treatment of Parkinson's tremor with medicinal substances that lower the tone of the parasympathetic nervous system. This includes scopolamine or duboisine. Thus, one can prescribe scopolamine in the form of drops: Scopolamini hydrobrom. 0.01, Nitroglycerini 0.005, Morphii mur. 0.1, Aq. destill. 10.0; from 4 to 6 drops 2 times a day.