Trembling is an almost normal reaction to any deep disturbance of the emotions.
The teeth chatter. The knees knock together. And this can become very embarrassing because most people try to conceal their feelings.
The person who trembles is written-off disparagingly as being highly strung.
This attitude is unfair because trembling is not consciously motivated. It depends on certain repressed fears and feelings of guilt in childhood. It may have no connection with a lack of courage.
But there are some who in ordinary domestic circumstances may develop a tremor so gross that nothing will hide it. Like the stammer, the more one tries to control it the worse it becomes.
This is called the intention tremor. It usually involves the hand which, normally quiet, commences to shake as soon as it is outstretched to take hold of some object.
It is characteristic of this type of tremor that the nearer the hand comes to the object of its grasp the greater becomes the amplitude of the tremor so that the object is knocked over before it can be grasped.
An intention tremor may be displayed by those suffering from hysteria. Though it cannot be controlled because the neuromuscular dissociation which underlies the disorder robs the mind of conscious effort, it seldom occurs when the patient is alone and believes that he is unwatched.
This may serve to distinguish it from similar types of tremors resulting from some organic disease of the brain.
The neurotic has a variety of tremors at his command, from the finest, almost imperceptible, shake to the most ungainly and clumsy type of movement. The tremor may be generalized, involving the trunk, limbs, and head, or maybe unilateral. It may only operate in one limb or may merely affect a single group of muscles.
Wherever it may be, it can be kept going for an astonishingly long time – far longer than the ordinary person could manage without fatigue.
Strange to say, the tremor is no embarrassment to the hysteric, whose indifference to what would seem like acute discomfort is proverbial. But the outward calm masks a state of mind in the very turmoil of conflict.
Some people are said to suffer from a hereditary tremor. Though normal in other respects, they apparently possess some congenital defect in the muscular co-ordinating mechanism.
This condition is sometimes familial and occurs mostly in children and young adults. Such a tremor is sometimes capable of arrest by a strong effort of will, and in many instances it tends to disappear with increasing age.
It is common knowledge that fatigue will cause tremors. The weakness of certain muscle groups after an illness is often responsible for tremor when movement is attempted. This may prove inconvenient, but otherwise, it is of little significance.
It is natural to shiver with cold. But here the generalized tremor not only serves as an indication of the cause of the trouble but is in itself a remedial measure brought about involuntarily as a means of promoting warmth by intense muscular action.
The origin of a tremor may be obvious. Its significance may be of little moment. But otherwise it should not be lightly passed by; for there are serious disorders in which tremor may be the first sign.
Any person of any age who develops a persistent tremor is advised to seek medical aid.
In a person of advancing years it may be a senile tremor for which little can be done. In this condition the oscillations affect the head and arms.
Head nodding is often the first sign noticed, but the tremor later extends to both the upper extremities. There is neither weakness nor rigidity of the muscles involved. The tremor ceases in repose and during sleep.
A fine, persistent tremor in a younger person may signify the onset of exophthalmic goiter. This is a fine, rapid tremor, affecting the hands mainly, though other parts of the body may become involved. It is increased by movement and excitement.
Because this type of tremor may be sudden in its onset, and frequently associated with attacks of palpitation and sweating, the illness may be mistaken for an anxiety attack, and adequate treatment deferred. An enlargement of the thyroid gland in the neck with a staring, frightened expression should help to clear the diagnosis.
A unilateral fine tremor is rarely seen but may occur in connection with a frontal tumor of the brain, when it will affect both the arm and the leg on the one side.
A fine and sometimes unilateral tremor may occur in chorea. But the more characteristic signs are the choreiform movements which give the sufferer an appearance of continual restlessness.
Chorea is associated with rheumatic fever, especially in children. It must be treated with the respect due to a serious complaint, though in most cases it is not fatal.
The intention tremor, already described as a neurotic manifestation, also occurs in disseminated sclerosis, a chronic type of brain disease, often affecting young people. Though remitting from time to time, disseminated sclerosis eventually renders them paralyzed and helpless.
Another grave disorder, now fortunately, less common than in days gone by, is known as general paralysis of the insane.
It is characterized by a variety of tremors, including in some cases the intention tremor. But more typical are the fine tremors of the facial muscles, and the so-called “trombone tremor” of the tongue, which tends to jerk backwards and forwards when the patient endeavors to protrude it.
Intoxication by alcohol, tobacco, cocaine, and morphia may cause the production of tremor. Alcoholic tremor is a fine, rapid, regular movement of the muscles of the hands and tongue, and in severe cases of intoxication it may become generalized.
It disappears during rest and is increased in movement and excitement. It is increased again by the want of further alcohol, which may lead to the development of delirium tremens. The cure, though difficult, is obvious.
We pass by other nervous diseases such as Friedreich’s ataxia and cerebellar disorders, as they are not frequently encountered. But the shaking palsy, or paralysis agitans, and Parkinson’s disease cannot be overlooked in a discussion on tremor.
Paralysis agitans occurs in the later decades of life and is due to degenerative changes in certain parts of the brain. It often commences with a typical fine tremor in the thumb and first finger. This has been called the “bread crumbling” or “cigarette rolling” tremor.
Beginning in one hand, the tendency is in time to spread into other limbs, the head, the lips, and the tongue. In fact, the whole body may eventually become involved with the tremor; muscular rigidity develops, giving a set expression to the face and a monotonous voice.
The condition is chronic and progressive. Little can be done to relieve it, although drugs of the belladonna group may for a time alleviate the more distressing symptoms.
As the result of an attack of encephalitis, sometimes after many years, certain people, either young or in the prime of life, develop Parkinson’s disease, which in many ways resembles paralysis agitans.
These unfortunate people are smitten with a chronic and disabling disease, in which the tremor and muscular rigidity become more marked as time goes on.
The face becomes mask-like. When they smile, the change breaks slowly over the facial muscles like a slow-motion picture. But otherwise the mouth hangs open and a continual dribble of saliva adds to their misery.
Physicians cannot cure, and can only relieve, the symptoms of Parkinsonism by prescribing increasing doses of relatively new drugs.
Surgery also plays a part in relieving the tremor in these cases. The operation is known as cordotomy, and neurosurgeons claim success in chosen cases.
It is a delicate operation in which the lateral column of the spinal cord is severed at the second cervical segment.
The immediate effect of the operation is to eliminate the tremor; but with it occur a temporary paralysis on the same side of the body and loss of the sensation of pain and temperature on the opposite side.
The paralysis disappears during convalescence, and the patient is left without a tremor, although his pain and temperature sense is defective on one side.
Such an operation should be undertaken before the tremor has spread to both sides of the body.
It may occasion risks that some surgeons would not undertake and some patients would decline. But neurosurgery is a young science, and this operation may well be but an earnest of what yet may be achieved.