disease. In some, especially in young patients the akinesia developed to a very high degree. Neglected by their family, half starved, such patients would lie in their beds with their limbs. rigidly fixed at the elbow and knee-joints, unable to move (Figure 2), except that their eyes, like search lights constantly moving from one place to another, betray that the patient is taking an interest in his surroundings. No wonder that superstitious people even among the nursing staff cannot overcome a certain feeling of fear at the aspect of such statue-like patients, which they believe to be possessed by some kind of evil demon. The typical tremor of paralysis agitans was absent in all cases of this group, but involuntary movements of various kinds from the finest muscular contractions to coarse tremors and extensive choreiform movements of the extremities were present in 75% of the cases (Figure 3). 8 patients displayed no hyperkinetic signs at all, although in a few of them those movements had been present before and had subsequently disappeared. Whereas the mask-like face can be considered a typical sign, in Parkinsonian patients of the yellow race I was not able to confirm another sign as being present in our Chinese patients, which we constantly observe in the same type of the white race, the so-called "ointment" or greasy face. This sign, therefore, cannot be considered as a significant feature of the Parkinsonian form of the disease among the Chinese. The natural appearance of the facial skin of the yellow race is of a somewhat shiny character, probably also the yellowish tint does not render differences in glamour so easily distinguishable as in the white race. In most cases the oculomotor nerve was involved with partial paralysis of one or several muscles; more or less increased salivation was another constantly present symptom. In 5 cases (4 men and 1 woman) and only in those of the Parkinsonian type compulsory movements of both eyes were observed. They were accompanied by a certain feeling of uneasiness and anxiety; one boy used to cry aloud at the onset of these attacks. The patients experience the feeling that they cannot move their eyeballs any more and are unable to turn them out of their forced direction to another side, except for a few seconds. In one case the attacks were accompanied by loud gargling sounds in the larynx; another patient spoke of these crises as attacks of blindness. In all patients the eyeballs were rolled up during the attacks and were fixed in this extreme upward direction for 5 to 10 minutes or even longer, then slight conjugate movements to one or the other side began in the way of a lateral or slightly rotating nystagmus until after 15 to 20 minutes the spasms gradually disappeared. The upward movement and fixation rigidity of the bulbi were regularly followed by a movement in the same direction and fixation of the head in extreme extension, which continued during the whole attack. The extremities during this period were also held in a flexed and rigidly fixed position. The eyes during the crisis could be closed only with great effort and soon resumed the former fixed position under rhythmic winking movements of the upper lids. In one case the movement and fixation of the eyes and head in the upward direction were immediately followed by a similar movement downwards of both eyes and head. The pupillary reaction was always preserved. According to the intensity of the spasms the attacks lasted from one to several hours, they often returned in somewhat regular intervals of 2-3 days, generally in the late afternoon. Fatigue of the eyes after long reading or prolonged gaze at an object was considered responsible by some patients for provoking the attacks. In another case the ocular crises were accompanied by a nystagmus like myoclonus of the left sternocleidomastoid muscle. In one instance these compulsory eye movements appeared very soon after the initial stage and formed the main symptoms of which the patient complained during the following year; at the end of this period other myostatic disturbances appeared. There was a remarkable staring glance of the eyes in all these cases. (Figure 4). The following case represents an example of the Parkinsonian forms: No. 40. Fan, merchant, aet. 17 y. Admitted October 1923. Begin January 1921 with lethargy continuing for 4-5 months, later the movements gradually became stiff and also the facial mimic expressions; increased salivation; since June 1922 after a fright rapid increase of the muscular rigidity. Status: Mask-like face, typical akinesia and bradykinesia, no tremor, the slow movements and the jerky play of the eye balls resemble much the behaviour of a chamelion. Marked rigidity: the mimic movements at the expressions of laughing and pain remain in the face for some time. (Fig. 5. ) Sensation: o.k. Tendon reflexes active, skin reflexes weak, no Babinski reflex. Skin dry, perspiration diminished, but excessive salivation. Pupils: right larger than left, normal reaction. Closure of eyelids quick, but opening slow (5-7 seconds with tremor of the upper lids), absent convergence, no corneal ring. |