Urban Observation and Sentiment in James Parkinson’s Essay on the Shaking Palsy (1817)

Abstract

James Parkinson’s Essay on the Shaking Palsy (1817) has long been considered the foundational text of the disease which now bears the author’s name. This paper shows how the Essay radically re-formulated a diverse array of human dysmobilities as a “species” of disease. Parkinson incorporated medical observation with a clear focus on patient experience and subjectivity in a deeply affecting narrative, fusing clinical and urban case-descriptions within the genre of a sentimental natural history. His detailed, diagnostic portrayal of the malady recast earlier descriptions of trembling, posture and gait disorder within a new narrative order, simultaneously recruiting reader involvement to the plight of sufferers. Hardly any clinical examination as we know it today undergirds what remains an exemplary account of disciplined medical witness. The Essay demonstrates the potential of case construction and powerful, sympathetic case writing to transform clinical understanding of a complex medical condition of long duration.

James Parkinson published An Essay on the Shaking Palsy in 1817, two years after the battle of Waterloo. The Essay set out a closely observed clinical account of a progressive, disabling condition, which was swiftly recognized to be an important description that since has attained the status of a classic medical text.¹ In the year of its publication the London Medical and Physical Journal announced the Essay worthy of “universal perusal” and reprinted substantial excerpts from it.² In his Treatise on Nervous Diseases of 1820, James Cooke, physician to the London Hospital, declared “Mr Parkinson’s Treatise” to be “highly deserving” of attention, and noted that until then nosologists had “not classed paralysis agitans among the palsies.”³ Part of the Essay entitled the “History” was quoted verbatim (without acknowledgement) in Thomas Graham’s 1827 edition of Modern Domestic Medicine, one of many popular treatises of the time designed to help people unable to pay doctors to diagnose and treat themselves.⁴ The Essay was referred to in early editions of The Lancet by prestigious physicians at the height of their careers, including John Elliotson in 1830 and Marshall Hall in 1838.⁵ International medical authorities also noticed Parkinson’s Essay: in 1846, the German physician, Marshall Romberg, in his Manual of the Nervous Diseases in Man; the French physician, Armand Trousseau, in his 1861 Lectures in Clinical Medicine; and that same year the distinguished neurologists, Jean-Martin Charcot and Edmé Vulpian.⁶ Charcot, who later named the condition “La Maladie de Parkinson”—an eponym that since then has held—was so impressed by the Essay that he advised students at the Salpêtrière to translate it. “It will provide you,” he said, “with the satisfaction and knowledge that one always gleans from a direct clinical description made by an honest and careful observer.”⁷

This paper takes seriously Charcot’s recommendation to engage with the Essay at the level of the text itself. It looks afresh at the work’s structure and content, locating the writing in the context of the culture of the day and in its affinities with eighteenth-century urban observation and the sentimental literature of Parkinson’s time.⁸ I will focus on how the Essay’s clinical phenomenology goes beyond the language of the ocular to include subjective perspectives on the effects of the condition, and on the way Parkinson characterized the natural history of the malady.⁹ This supports a reading of the Essay as a sentimental story—one which, through a poignant rendition, recruits the emotional and intellectual engagement of readers to the suffering that the condition causes, and which adds to the Essay’s achievement and endurance as an exemplary medical text.¹⁰

The Author

James Parkinson (1755–1824) worked as a general practitioner in the semi-urban hamlet of Hoxton, north east of the City of London, where he had been born, and where he lived all his life (see Figure 1).¹¹ The historian Roy Porter considered Parkinson a man “with impeccably enlightened credentials,” a doctor with a highly developed empiricist bent, committed to observation and recording of the human and natural worlds, and faithful to social and political ideals including widening of the franchise and improvements in the material conditions of the majority of people.¹² In addition to his daily work in general practice, James Parkinson was a public health reformer, an advocate of infection control in London workhouses, a medical attendant to a Hoxton madhouse, a writer of political pamphlets and children’s stories, a geologist and fossilist, and the author of a textbook of chemistry.¹³

Figure 1.

Greenwood Map of Hoxton and Shoreditch, 1827. Stars: almshouses, madhouses or workhouses. Unlabeled arrows point to: St. Leonard’s Church Shoreditch, Parkinson’s place of retirement in 1817, and St Luke’s Mental Asylum. Map hosted by Bath Spa University, U.K.: http://users.bathspa.ac.uk/greenwood/. Website author: Mark Annand. Copyright permission has been granted.

The Essay’s Structure

In the Essay Parkinson redefined a hitherto imprecise term, “paralysis agitans,” as the “Shaking Palsy,” so as to designate henceforth a specific conjunction of major symptoms which manifest in afflicted patients as a slowly debilitating disorder of movement that ultimately proves fatal.¹⁴

The body of the Essay is divided into five chapters. The first of these is its most important and capacious section, presented in three parts: “DEFINITION—HISTORY—ILLUSTRATIVE CASES.” Parkinson first defined the condition, then located its features as the conjunction of already described components of movement disorders previously believed separate and unrelated, and contended that the different components coexisted in the Shaking Palsy. He characterized the malady in a detailed description in the “History,” and rounded off this opening chapter with six case histories.

In chapter 2, “PATHOGNOMONIC SYMPTOMS EXAMINED—TREMOR COACTUS—SCELOTYRBE FESTINANS,” Parkinson returned to his definition and presented two components as “pathognomonic” (definitive) of the Shaking Palsy. Chapter 3, “SHAKING PALSY DISTINGUISHED FROM OTHER DISEASES FROM WHICH IT MAY BE CONFOUNDED,” sought to differentiate the malady from similar conditions and to establish the Shaking Palsy as a “species of disease.” In the fourth chapter, “PROXIMATE CAUSE—REMOTE CAUSES—ILLUSTRATIVE CASES,” he outlined possible causes of the condition, referring to a number of cases including several from his own practice. Finally, in chapter 5, “CONSIDERATIONS RESPECTING THE MEANS OF CURE,” Parkinson outlined two stages of the affliction and suggested that in the earlier stage the condition might be curable with local treatments.

The Essay’s Definition of the Malady

Parkinson defines the Shaking Palsy thus: “Involuntary tremulous motion, with lessened voluntary 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 a running pace: the senses and intellects being uninjured.”¹⁵

Although this was a definition not previously advocated, its elements were not in themselves novel: they had long been recognized separately and placed in different classes, species, and genera of prevailing nosologies, or disease classifications. The components Parkinson believed necessary for the diagnosis were these: Tremor coactus (a term referring to an involuntary trembling characterized by the Dutch physician and anatomist Franz de le Boë in the seventeenth century) and Scelotyrbe festinans (a conjunction of scelotyrbe, an ancient Greek term for hustle or totter, and festinans, the Latin signifying hurry).¹⁶ Parkinson’s key contribution was to argue that these already classified dysmobilities in fact belonged together, and that they constituted a single malady.

The Essay’s “History”

The definition is followed by a section of the Essay entitled “History” that set out a generic account of the Shaking Palsy, featuring details selected from the cases. The individual cases immediately follow the “History,” readers thereby encountering an iterated clinical narrative: a generalized story of the malady told in the “History” and in a patchwork of separate narratives made up of the case descriptions.

The “History” is worth quoting at some length because it detailed a complex trajectory of shaking, agitations, and altered gait developing slowly over time:¹⁷

So slight and nearly imperceptible are the first inroads of this malady, and so extremely slow its progress, that it rarely happens, that the patient can form any recollection of the precise period of its commencement. The first symptoms are a slight sense of weakness, with a proneness to trembling in some particular part; sometimes in the head, but most commonly in one of the hands and arms.

…[A]s the disease proceeds … the hand fails … to answer with exactness to the dictates of the will…. The legs are not raised to that height, or with that promptitude which the will directs…. [W]riting can now be hardly at all accomplished … whilst at meals the fork not being duly directed frequently fails to raise the morsel from the plate. Commencing … in one arm, the wearisome agitation is borne until beyond sufferance, when by suddenly changing the posture it is for a time stopped … to commence, generally in less than a minute in one of the legs…. Harassed by this tormenting round, the patient has recourse to walking, a mode of exercise to which sufferers from this malady are in general partial; owing to their attention being thereby somewhat diverted from their unpleasant feelings….

[A]s the malady proceeds … the propensity to lean forward becomes invincible, and the patient is thereby forced to step on the toes and fore part of the feet, whilst the upper part of the body is thrown so far forward as to render it difficult to avoid falling on the face…. In some cases … the patient … is irresistibly impelled to take much quicker and shorter steps, and thereby to adopt unwillingly a running pace.

The power of conveying the food to the mouth is at length so much impeded that he is obliged to consent to be fed by others. The bowels, which had been all along torpid, now, in most cases, demand stimulating medicines…. [H]e dares not venture on exercise, unless assisted by an attendant, who walking backwards before him, prevents his falling forwards, by the pressure of his hands against the fore part of his shoulders. He is not only no longer able to feed himself, but when the food is conveyed to the mouth, so much are the actions of the muscles of the tongue and pharynx impeded by impaired action and perpetual agitation, that the food is with difficulty retained in the mouth until masticated; and then as difficultly swallowed.… [T]he saliva … hence is continually draining from the mouth, mixed with the particles of food…. As the debility increases … the tremulous agitation … becomes so violent as to shake the bed-hangings. The chin is now almost immovably bent down upon the sternum. The slops with which he is attempted to be fed, with the saliva, are continually trickling from the mouth. The power of articulation is lost … and at the last, constant sleepiness, with slight delirium, and other marks of extreme exhaustion announce the wished-for release.¹⁸

The clinical arc of the malady is depicted pictorially in prose whose exactitude and pathos bear the weight of a human tragedy. It is articulated by a surgeon-apothecary who, like many doctors of his day, had sat with dying patients. Following an onset located in indistinctness the sufferer undergoes a long deterioration unflinchingly charted in chronological, semi-biographical terms. The closing scene focuses down on the sufferer, cared for and tended to (“attempted to be fed”) whilst tethered to his curtained bed by the condition. In the course of the narrative a marked transformation has become evident: hitherto upright, independent, and mobile (though becoming less so as the “History” unfolds), the exhausted sufferer has been made recumbent, chin-on-chest, still shaking, surrounding furnishings also shaking, the movements disappearing only when “constant sleepiness” and “slight delirium” set in, and death supervenes.

This is not a conventionally “good death” for the period: the picture is of “a train of harassing evils” followed by an agitated transition to a welcome repose.¹⁹ The sufferer is an individual who is in fact a composite—derived as we shall see from a series of cases—hence a fiction, but a fiction based on careful observation of real people and their circumstances. The “History” follows this invented individual, whose daily activities, habits, and propensities have become progressively curtailed, Parkinson’s use of impersonal constructions and the passive voice lending power to his depiction overall of frustrated volition. By taking parts of the sufferer’s body as the subject of his sentences (“the hand fails,” “the legs are not raised,” “the fork … fails,” “the chin is … bent down”) and making the man the subject of passive verbs (“the patient is irresistibly impelled,” “he is obliged to consent to be fed”), Parkinson’s syntax mirrors the condition the man finds himself in, of being unable to exercise his will over his own body. The fact that it is “the hand” of this sufferer that “fails” and not “his hand” is also telling, as it conveys the sense of alienation he must feel from his own body.²⁰ The sufferer’s growing helplessness (“the patient is irresistibly impelled” and “obliged to consent to be fed”) terminates the affliction in a death that “softens the heart” even as it closes the section of the Essay which charts the trajectory of a disease type.²¹

The Essay’s Illustrative Cases

Six “Illustrative Cases” immediately follow the “History.” All but the last are brief. The first of them reads:

Almost every circumstance noted in the preceding description, was observed in a case which occurred several years back, and which, from the peculiar symptoms which manifested themselves in its progress; from the little knowledge of its nature, acknowledged to be possessed by the physician who attended; and from the mode of its termination; caused an eager wish to acquire some further knowledge of its nature and cause. In this case, every circumstance occurred which has been mentioned in the preceding history.²²

Case I is the Essay’s first simply because it was the first Parkinson recognized as noteworthy, the first to stimulate his interest in characterizing the condition, his “index” or exemplary instance of it. By comparison with the “History” its prose is brief and pared down, and the clinical details are minimal. Whether this case history was entirely coincident with the “History” or parasitic upon it is not quite clear. That the “History” could be a direct transcription of Case I seems doubtful because analysis of the “History” reveals it to be a compound account interwoven with the details of other cases, including a highly distinctive scene of locomotion initiation from Case V which could not possibly have belonged also to Case I. But from Parkinson’s reference to “the mode of its termination” (my emphasis), it does seem likely that the deathbed scene so graphically portrayed in the “History” is derived from what happened to the first case.

To a modern reader it might be surprising how little clinical content Case I contains—how non “illustrative,” in terms of the clinical features visualized, Case I turns out to be. One might assume the contents of Case I to be pivotal to convincing modern readers that the general description of the condition is grounded in careful observation of clinical reality, but the generic description of the Essay’s “History” is much more detailed than that of Case I, which reverses modern expectations.

Parkinson introduced his second and third cases, as “the subject of the next case” and “the next case,” indicating these were consecutive observations. Both were derived from observations concerning people he stopped and questioned on the street. Each is short, and focuses on the bowed posture, curious gait, and the use of a stick. The man in Case II, Parkinson reported, “walked almost entirely on the fore part of his feet, and would have fallen every step if he had not been supported by his stick.”²³ The sufferer advised that the condition had come on “as the consequence of irregularities in mode of living and indulgence in spiritous liquors,” an attribution Parkinson faithfully reported but does not credit, as he maintains that the trembling of the Shaking Palsy is quite distinct from that related to a habitually high intake of alcohol.²⁴ Case II concerned a man of sixty-two years of age “whose life had been spent as an attendant at a magistrate’s office. All the extremities were considerably agitated, the speech was very much interrupted, and the body much bowed and shaken.”²⁵

Parkinson reported that the agitation of Case III’s limbs, head, and body was “vehement” and coexisted with abnormal posture and gait: “he was entirely unable to walk; the body being so bowed, and the head thrown so forward, as to oblige him to go on a continued run ... and to employ his stick every five or six steps to force him more into an upright posture, by projecting the point of it with great force against the pavement.”²⁶ The reader cannot fail to be struck by how closely observed and visually alive are the case descriptions from the street.

Case IV Parkinson saw indoors: “The next case which presented itself was that of a gentleman about fifty-five years” who consulted on account of a chest complaint. This turned out to be due to an abscess, “a considerable degree of inflammation over the lower ribs on the left side, which terminated in the formation of matter beneath the fascia.” Whilst Parkinson was draining it he noticed a feature of the Shaking Palsy referred to simply as “trembling of the arms.”²⁷ Although this case adds to the number in his case series, its sketchy details contribute little to the characterization of the malady. However, from Case IV we gain a sense of Parkinson at work, and learn that the trembling of which he speaks may not always lead sufferers to complain of shaking, even when consulting on account of other conditions. The diagnosis may be made opportunistically.

Parkinson did not get the chance to speak to Case V because, as he put it, “the lamented subject … was only seen at a distance.”²⁸ But he offered the following sketch of how his mode of propulsion was initiated and sustained by an attendant who, “standing before him with a hand placed on each shoulder, until, by gently swaying backward and forward, he had placed himself in equipoise; when, giving the word, he would start in a running pace, the attendant sliding from before him and running forward, being ready to receive him and prevent his falling.”²⁹ Parkinson’s deft description vividly conveys a curious and unusual mode of co-operative locomotion initiated through a to-and-fro rocking motion in unison, the sufferer in effect only managing to start moving by falling his way forward, being protected from an actual fall by the diligent maneuvers of a faithful attendant. The scene Parkinson evokes is almost cinematic.

We come now to Parkinson’s sixth case, which he introduced as one “which presented itself to observation since those above-mentioned,” a case perceived with the benefit of hindsight gained from the other cases in his series. Textually longer than the first five, it charts a sequence of symptoms occurring in a man over a twelve-year period. As in the other case histories, Parkinson contextualized the effects of the malady on the sufferer’s life, reporting the patient’s own views about its causation and its vexations: his bowels, for example, were “much retarded,” a problem Parkinson believed common to other sufferers; the man’s trembling was temporarily banished by a stroke, only to return as the one-sided paralysis of his body resolved.

Parkinson twice noted this man’s capacity temporarily to suspend the agitation by his own will: “At present he is almost constantly troubled with the agitation … when, by a sudden and somewhat violent change of posture, he is almost always able to stop it,” and “he, being then just come in from a walk, with every limb shaking, threw himself rather violently into a chair, and said, ‘Now I am as well as ever I was in my life.’ The shaking completely stopped; but returned within two minutes.”³⁰ The note of triumph which rings out from this snippet of reported speech from two hundred years ago is unmistakable as the man demonstrates his self-discovered auto-termination method (as it would now be named). Maneuvers of this sort, devised by patients craving a moment’s peace, are familiar to patients and doctors in the present day.³¹ The scene reveals not only this sufferer’s agency and ingenuity (albeit only transiently effective) but his satisfaction, also, in being able to teach his doctor something important about the condition.

As Case VI reaches its close, another voice enters the conversation, that of the patient’s wife. Parkinson recounts:

It … being asked if he walked under much apprehension of falling forwards? he said he suffered much from it; and replied in the affirmative to the question, whether he experienced any difficulty in restraining himself from getting into a running pace? It being asked, if whilst walking he felt much apprehension from the difficulty of raising his feet, if he saw a rising pebble in his path? he avowed, in a strong manner, his alarm on such occasions; and it was observed by his wife, that she believed, that in walking across the room, he would consider as a difficulty the having to step over a pin.³²

Parkinson’s interviewing calls forth highly informative responses with the sense of affirmation from husband and wife being palpable as the doctor’s questions reveal his grasp of the condition: confirming the patient’s fear of falling, his apprehension of stepping over small objects (“a rising pebble in his path”), and his tendency to forward running, all bring out something of the patient’s psychological as well as physical vulnerability. A respectful relationship among those present is reflected in the space the text creates for three viewpoints: the doctor’s keen understanding, the patient’s subjective experience, and the wife’s insightful observation of her husband’s condition.

The Essay’s Later Chapters

In chapter 2, Parkinson sought to anchor his account of the malady in already described modules of human dysmobility. The pathognomonic features (necessary to identify and diagnose) he locates in Tremor coactus and Scelotyrbe festinans, which had been recognized separately in classificatory schemata of the day. In chapter 3, Parkinson endeavored to distinguish the Shaking Palsy from other trembling disorders, and in chapter 4 he presented his own observations on the causes of the malady. In chapter 4 he referred to a number of additional cases, not in his own series. One of these, another street case, concerned a man who had suffered agitation and convulsive movements of the legs following mercury treatment for a venereal infection many years before: “Full ten years later,” Parkinson wrote, “the unhappy subject … was casually met in the street, shifting himself along, seated in a chair; the convulsive motions having ceased, … and the limbs having become totally inert … and insensible to any impulse of the will.”³³ Parkinson was at pains to distinguish this pattern from the Shaking Palsy. He knew very particular things about this man whom he had met “casually” in the street, as he put it, which may well mean they were not strangers to each other. In all probability the man may once have been one of Parkinson’s patients, though there seems to have been no mutual sign of recognition.

In chapter 5, Parkinson expressed his hopes for successful trials of treatment. Early diagnosis was essential, he argued, if there was to be a chance of cure. Citing a successful case report (that of Count de Lordat) which he perceived as analogous, Parkinson suggests that the condition should be divided into an early phase—within two years or less of the first referable symptom—and a later phase. Late-stage disease, he held, offered little hope of alleviation. But early on, the disease might be curable if blood were to be withdrawn from the upper part of the neck, or if blistering, scarifying, and drainage of either side of the uppermost vertebrae were to be tried, so as significantly to reduce inflammation in that region. This idea reflects Parkinson’s provisional conclusion that the origin of the malady might be found in congestion or inflammation of the spinal medulla.

Medical Observation in Parkinson’s Day

Parkinson believed his occupational position gave him a key vantage point for his observational synthesis. Because of the disease’s long duration, he wrote, “to connect, therefore, the symptoms which occur in its later stages with those which mark its commencement, requires a continuance of observation of the same case or at least a correct history of its symptoms, even for several years.”³⁴

But it is not only observational continuity that underpins Parkinson’s achievement. Also important is his ability to select and situate salient features of his daily practice emerging out of conversation, questioning, and prolonged follow-up, and to embody these narratively in a text that bears witness to complex and evolving clinical appearances developing slowly over time.

It is difficult to overstate the importance of personal witness in the clinical accounts of his day. In the Preface to his Commentaries on the History and Cure of Diseases of 1802, the highly accomplished physician William Heberden (1710–1801) wrote: “The notes from which the following observations were collected, were taken in the chambers of the sick from themselves, or from their attendants…. These notes were read over every month, and such facts, as tended to throw any light upon the history of a distemper, or the effects of a remedy, were entered under the title of the distemper in another book, from which were extracted all the particulars here given.”³⁵

Heberden’s method of chronicling his daily work, mulling over its details and later abstracting what he judged relevant into a separate volume, fashioned the Commentaries and enabled him to claim a close match between the contents of his textbook and everyday clinical experience.³⁶

Heberden was a Fellow of St. John’s College Cambridge, the Royal Society and of the Royal College of Physicians, and the founder-editor in 1785 of its Medical Transactions. Parkinson was a surgeon-apothecary from the East End of London—a generation junior to Heberden—who had been apprenticed to his own father, and who had spent six months in Whitechapel walking the wards of the newly-established London Hospital. Yet Heberden and Parkinson shared interests: they were early members of the Humane Society (founded in 1774); each had published case reports in the early volumes of the Memoirs of the Medical Society of London; and each had an interest in the effects of lightning on people and on property.³⁷ While no direct evidence connects the two men, Parkinson is likely to have been familiar with Heberden’s Commentaries, which had appeared in Latin (a language Parkinson read well) in 1802, and which by 1817 had attained wide currency, having appeared in three editions, including an English translation. Heberden’s popular textbook therefore provides a gauge of contemporary clinical understanding of disorders of shaking. A “trembling of the hands or a shaking of the head,” Heberden had written,

may be judged to have some alliance with paralytic, and apoplectic maladies; yet it has often continued for a great part of a person’s life, without any appearance of further mischief; and therefore, if it have a tendency to palsies, it is a very remote one…. Hypochondriac persons are troubled with frequent fits of it; hard drinkers have it continually; and some degrees of it usually attend old age. This, like other affections of the nerves, is greatest in a morning, and is aggravated by any disturbance of mind. Coffee and tea make the hands of some persons shake; and yet I have known strong coffee drunk every day for forty years, by one who was remarkable for the steadiness of his hands even in extreme old age.³⁸

Heberden’s account of trembling is neither closely observed nor rendered in particular detail, and in pointing to its association with other conditions—old age, hypochondria, heavy intake of alcohol or coffee—he posited no new connections. He noticed no relationship between trembling and disorders of posture or gait, and he made no reference to classifications of tremor such as those of Boissier De Sauvages or William Cullen, to both of whom Parkinson referred in the Essay. De Sauvages’s Nosologia Methodica of 1762 had defined tremor as a “side-to-side movement without a feeling of being cold,” and nineteen species of it were listed in his fourth class of disease, “Spasm and Convulsive Malady.”³⁹ Cullen’s Nosology (1800) had defined tremor as “an alternate and frequent motion of a joint to-andfro,” fifteen species of which were outlined under his second class of disease, the “Neuroses.” Both authors referred to this form of shaking as Tremor coactus.⁴⁰

The other component of the disorder outlined in the Essay was Scelotyrbe festinans, a tottering or hurrying gait that Hieronymus Gaubius had described in 1772. Gaubius, Professor of Chemistry and Medicine at Leiden, had reported, “it happens that the muscles by an involuntary agility and impetuosity accelerate their motions and hurry away against the determination … [he had] seen those who could run but not walk.”⁴¹

De Sauvages had identified several forms of scelotyrbe but associated none of them with trembling: Scelotyrbe of Galen, he had noted, was “an impediment which prevents people walking in a straight line,” which he had likened to the seventeenth-century physician Thomas Sydenham’s description of Saint Vitus’s Dance.⁴² Scelotyrbe festinans De Sauvages defined as a disorder of people who can only locomote in haste, illustrating this with the case of a fast-walking, elderly painter unable to divert his path “to the right or left, and on meeting an obstacle became almost fixed until, little by little, by shifting his position, he once again began to move forward in a straight line.”⁴³ Parkinson argued that a compound of these complex disorders of movement is the result of a single disease, the Shaking Palsy. As he explained at the end of his first chapter: “The … cases appear to belong to the same species: differing from each other, perhaps, only in the length of time which the disease had existed, and the stage at which it had arrived.”⁴⁴

Parkinson’s use of the term “species” is typical of a late eighteenth-century physician-naturalist. Thomas Sydenham earlier had urged doctors to identify and classify diseases with the same exactitude as botanists bring to bear on the characteristics of different plants.⁴⁵ _Parkinson was one of the most experienced fossilists of his day, an adept at classifying fossil types, and probably considered the Shaking Palsy a newly-recognized “species of disease” in the same sense as applied to newly discovered fossils and plants of the period.⁴⁶

Urban Observation

The Essay is pervaded with acute observation, reflecting the best medical habits and values of the day. Parkinson drew on observations of people who consulted him as well as of others who were not his patients, some of whom he questioned on the street. The busy-ness of London streets had increased throughout the eighteenth century as the metropolitan population doubled and commerce expanded. Much trade and transaction took place on the street, which accommodated a wide variety of occupations and became an environment in which people were required to be hyper-alert, to negotiate and navigate street obstacles and dangers.⁴⁷ The cries of London—the custom of street sellers singing out “street cries” to advertise their goods—and the huge contrast between urban traffic and that in the countryside became the subject of observation and comment.⁴⁸ In the mid-eighteenth century, Dr. Johnson relished posture, bearing, and gait as signals of class, attitude, and intention given off on the street, such aspects physiognomically conveying moral as well as morbid temperament.⁴⁹

Visitors to London were struck by its street life: in 1782, for example, the German author and essayist Karl Philipp Moritz included vivid street impressions in his letters.⁵⁰ The poet Heinrich Heine, visiting the capital ten years after the Essay’s publication, wrote: “Send a philosopher thither [to London] and set him at the corner of Cheapside, and he will learn more than from all the books of the last Leipzig fair; and as the waves of human beings roar about him there will arise before him a sea of new thoughts … and … reveal to him the most hidden secrets of the social order.”⁵¹ Heine’s reaction brings out just how revelatory London street life was to visitors in the early nineteenth century, animation and social mixing being prominent features of street images of the period.⁵²

Cheapside then was a fashionable thoroughfare known for its opulence, which an 1823 view (Figure 2) confirms not only in its splendor but also in the mingling taking place in the street. The pavement is portrayed as the ordered meeting ground of different occupations, activities, trades, and modes of travel, including differing body types and shapes, postures, and gaits: people are shown stooping, lugging, pushing, pulling, carrying, and stepping forth. London had no public transport system, and many of the streets, even major thoroughfares, were congested with foot and wheeled traffic, and were generally a good deal less orderly than this view of Cheapside suggests. Before the great Post Office was erected, St Martin-le-Grand, for example, near St. Paul’s Cathedral, was dirtier and poorer (see Figure 3).⁵³

Figure 2.

Cheapside in 1823. Engraved by T. M. Baynes from a drawing by W. Duryer. Author’s Collection, author’s own copyright.

Figure 3.

St. Martin-le-Grand (1819). View on the street looking towards St. Paul’s Cathedral, the dome of which rises prominently in the central background. The street is busy with a cart and a wagon, men on horseback, a street sweeper, street traders and pedestrians; the section of street shown was to become the site of the new central Post Office. Etching and aquatint British Museum Prints and Drawings. Copyright permission granted.

The streets abutting Hoxton Square, where Parkinson lived and worked, were probably almost as busy as these better-known locales, but with the activities of a different kind of population. Parkinson’s home and surgery at Number 1 Hoxton Square stood on a corner with a view across the square to the front and over the main eastern approach to Hoxton market at its flank and rear (see map, Figure 1). His apothecary’s shop and surgery were on the ground floor with family accommodation in the house above. To the north there were market gardens and orchards and, further away, open fields and farms. Such peripheral parts of London were subject to daily tidal movements of people entering the village by foot, some no doubt to stay, others on their way to the city to work, trade, and purchase goods, retracing their footsteps later in the day. Many on the streets would have been elderly, as Hoxton had an unusually high number of almshouses and workhouses in its locality (see Figure 1).⁵⁴

The nearest major road junction to Hoxton Square is shown in Figure 4. The engraving (ca. 1800) shows the four-way intersection of Shoreditch High Street and Hoxton High Street. The apothecary’s shop in the left foreground was not Parkinson’s, but might suggest its likeness. At this crossroads the artist has provided a number of pedestrian portraits with pronounced postures, including a man stooping, and others crouching, carrying buckets, and pushing a trolley. Another view of the same church (Figure 5) shows a figure with an apparently dragging gait (with his back towards us) which might stem from a stiff left hip, as well as a sailor strutting forth, walking in the opposite direction. In noticing posture and gait in settings around Hoxton, Parkinson was, I suggest, partaking in an observational culture shared by visual artists well-practiced in interpreting urban corporeality.

Figures 4 and 5.

(ca. 1800). The junction by St. Leonard’s Church Shoreditch, London. Author’s Collection, author’s own copyright.

It was a culture also shared by literary artists, reporting on the capital’s life in the tradition of earlier writers such as Ned Ward, Richard Steele, and Joseph Addison. In his novel Humphry Clinker (1771), the Glaswegian surgeon and novelist Tobias Smollett rendered the impression urban life made on arrival of country folk in the capital. People in the streets were “rambling, riding, rolling, rushing, jostling, mixing, bouncing, cracking, and crashing in one vile ferment…. [O]ne would imagine they were impelled by some disorder of the brain, that will not suffer them to be at rest.”⁵⁵ Urban street appearances are also a powerful presence in Lawrence Sterne’s A Sentimental Journey (1768). In one of its sentimental stories the protagonist Yorick notices a number of dwarfs in Paris: “I measured every body I saw walking in the streets…. Especially where the size was extremely little—the face extremely dark—the eyes quick—the nose long—the teeth—the jaw prominent—every third man a pigmy—some rickety heads and hump backs—others with bandy legs … arrested by the hand of Nature.”⁵⁶

Sentimental fiction of the period was structured in episodes, presenting a protagonist-hero in a linear series of encounters, featuring “tableaux or ‘scenes’ of those in distress”⁵⁷ in vignettes that aimed to engender “feelings of a tender heart, the sweetness of compassion, and the duties of humanity,”⁵⁸ effects case narratives also sought in the context of more factual scenarios concerning the poor, injured,

disabled, sick, and dying.⁵⁹ Parkinson was deeply familiar with the idiom—he had adopted it, to powerful effect, in penning children’s stories—and medical accounts that extended and deepened understanding of intractable conditions in the period also adopted this genre.⁶⁰

Sentimental writing in Parkinson’s time fashioned links between author and reader. Writing to a cousin in the 1770s, Henry Mackenzie (author of The Man of Feeling of 1771), explained that sentimental writing works by depicting details readers recognize, allowing them to feel “that pleasure which is always experienced by him who unlocks the springs of tenderness and simplicity.”⁶¹ The “man of feeling,” it has been argued, was also “a man of seeing who sees by moving through society,” whose “social observation and introspection” were stimulated by the objects of inquiry.⁶² In its consecutive narrative focus on special moments of poignancy, the Essay’s “History” can be read, then, as a constructed series of sentimental episodes whose truth to life is bolstered by the brief documentary form of the “Illustrative Cases.”

Parkinson’s Way of Seeing

The concept of the “medical gaze” developed in the twentieth century by Michel Foucault referred to a way of looking that emerged from Enlightenment thought. The term came to express a detached, de-personified view of illness; the “medical gaze” arose in hospital regimes which instituted a scientific discourse and system of power over patients.⁶³ More recently, however, the eighteenth-century historian Jessica Riskin has argued that sensibility and empiricism in the French Enlightenment could be intermingled. Riskin coins the term “sentimental empiricism” to refer to a distinctive mode of eighteenth-century French science, which acknowledged a responsiveness felt by scientists towards the objects of their inquiries.⁶⁴ This responsiveness, Riskin argues, generated observations “not from sensory experience alone, but from a combination of sensation and sentiment” and produced “natural … and moral sciences … that married physical sensation with emotion and moral sentiment.”⁶⁵

There is no doubt that Parkinson was an enthusiastic classifier of his extensive fossil collection, but his clinical observations were not, I argue, carried out in the spirit of what Lorraine Daston has referred to as “proprietary staring”; in practice, they were more akin to Riskin’s looking than to Foucault’s.⁶⁶ Parkinson’s regard of (and for) the sufferers of the malady he described in the Essay suggests “a more complex form of visuality” than staring with a Foucauldian “faceless gaze.”⁶⁷

Parkinson’s way of looking was not that of a spectator unconnected to the objects of interest, subordinated to taxonomic or other drives, nor was it the sort of viewing Walter Benjamin suggestively called “botanizing on asphalt”; rather, it was that of an observer alert to indoor and outdoor appearances, rooted in the urban and medical geography of his practice.⁶⁸ Parkinson had walked the locality of Hoxton since a child, and as an apothecary would have been on the streets to visit the sick at home. What he saw in and from his shop, and on foot, were people with whom he would have identified. It is this local, urban context which situates the Essay.

Yet the outdoor dimensions of Parkinson’s Essay have gone unnoticed in recent studies in the history of science focusing on towns as privileged sites for the conduct of scientific work: the roles of urban institutions—museums, libraries, royal colleges, hospitals and laboratories—in supporting scientific observations, experiments, and public demonstrations.⁶⁹ To such pervasive interactions between nineteenth-century science and its urban context can now be added Parkinson’s interest in the metropolitan streetscape as a locus for disciplined clinical observation, reasoning, and literary record.

In the context of the eighteenth- and nineteenth-century street, Parkinson employed what today is referred to as “field neurology” and “bystander” or “passer-by” diagnosis.⁷⁰ In the seventeenth century Sydenham had observed choreiform disorders in crowds in the open air, and had described the complex behavioral gestures of particular sufferers, but his outdoor observations were not made in the individualized, case-based manner in which Parkinson characterized dysmobilities on the streets of Hoxton.⁷¹

Parkinson’s Hopes for His Essay

The Essay appeared toward the end of Parkinson’s working life, and was the culmination of a multiplicity of clinical, collecting, and writing practices. Publication may have been delayed, both on account of the long period of follow-up and because he was all too aware that the claims advanced in the Essay were tentative, “mere conjectural suggestions” that lacked an etiological basis and for which he could offer relatively ineffective treatments.⁷² Parkinson positioned the work as a mere essai in which “analogy is the substitute for anatomical examination” and he justified its premature publication in 1817 by reference to the “highly afflictive” nature of the malady.⁷³ Given this degree of caution, the effects of its publication were almost epiphanic. Although some thirty years later The Lancet pondered whether the absence of French case-reports signaled that the condition might be widely variable in its prevalence, once the Essay was publicized beyond the United Kingdom the malady began to be diagnosed, and international refinements of its characterization followed.⁷⁴

“A Species of Disease”

Parkinson claimed he had identified something more than a loose collection of symptoms. For him the Shaking Palsy was “a species of disease,” a claim that has been sustained for nearly two centuries and which underpins the present-day utility of the eponym. The Essay reframed already-known clinical phenomena demarcating particular clinical appearances of the Shaking Palsy from other kinds of disease. But his claim that the Shaking Palsy was “a species” could be buttressed only by supplying evidence of something that holds together a very diverse set of symptoms. Without a convincing etiology, a causal account of its pathology, or a proven cure, this something is provided by the Essay’s narrative unity, which served to fuse an array of phenomena into a single malady.

The “History” achieves coherence in two ways. First, its logical role is to function as a dominant narrative that entails the disease-related details of the cases: the “History” provides an account of the malady in which nothing of salience that occurs in the cases has not already been pre-enacted—pre-destined—by the “History.” Second, as the “History” unfolds, a dynamic is unveiled inexorably working itself out within the sufferer. An entity or force is thereby created that narratively suggests an agency or entity operating beyond the level of discourse. However, because this agency functions obscurely Parkinson cannot distinguish it “as the malady proceeds” from different disease entities which cause very similar symptoms. Parkinson was aware of this difficulty and argued that although the Shaking Palsy was definitionally composed of already-recognized modules of disordered movement, what he had newly discovered was a clinical ensemble of highly distinctive temporal trajectory.⁷⁵ In effect, the Essay conferred a vivid and convincing narrative identity on this clinical ensemble.

The subject of this narrative is not in fact a sufferer but the malady itself, the unfolding ravages of which exert a relentless forward pressure on the account. And because the malady itself is a non-material abstraction—a conceptual entity or “species” that cannot exist separately from a patient—it operates through the grip it exerts on the “History’s” invented sufferer, who stands for all sufferers of the condition. His is an extremely vulnerable position, a victimized state, subjected to all the possible ill-effects the malady can inflict.

This victimized position is paralleled by the lack of any attempt on the part of the sufferer to seek help or medical attention: the “History” in effect abstracts him away from the world of any medical help. Whereas help-seeking is documented in the “illustrative cases” in which consultations take place, the “History’s” notional sufferer is not inserted into a meaningful patient context. Yet he is sensible: he is aware of his own physical deterioration, can think, feel, attempt (and fail) to recollect the onset of the condition, adapt, strive, and feel unable to thwart the worst ravages of the malady. The sufferer’s sensibility is recognized by that of his doctor, in whose voice the narration is presented as a chronicle of inexorable human decline which recruits the reader’s sympathy for every person subjected to the malady, a sympathy that operates as “a moral and social force of solidarity.”⁷⁶ Those who read the “History” perceive the disease through Parkinson’s sensibility which renders the account an exemplary chronicle of suffering, and of witness.

This is one of the reasons why the Essay remains important to clinicians today. Another is that it so powerfully conveys how clinical experience is inextricably linked to, yet can also break out of, the conceptual frameworks of an era. Parkinson believed the origin of the disease, or at least important signs of it, would be found in damage to the spinal medulla. But although he clearly allied himself to anatomico-pathological explanations of disease, in Parkinson’s lifetime these were some distance away from identifying the condition’s pathological causes or mechanisms. Parkinson’s approach to therapy—reduction of inflammation by the extraction of blood—reveals older theories of health and disease at work in his thinking influenced by the humors, and that he worked between the old and the new, the humoral and anatomico-pathological ideas of early nineteenth-century medicine.

In narrative terms, the “History” of the Essay differs in other ways from that of the cases, which pertain to real people, signified not only by snippets of biographical information, but also by reported speech between sufferers and Parkinson himself. By contrast, the sufferer of the “History” is not individuated and lacks any biographical referents apart from gender. His chief role is to render apparent the full effects of the malady.

The Essay and Modern Conceptions of Parkinson’s Disease

The era in which Parkinson trained helps to explain why the Essay laid no particular store on the assessment of patients by clinical examination. As the nineteenth century progressed, however, physical examination, informed by clinical science, would become central to clinical work. Additional aspects of the malady could then emerge and rigidity (due to increased body tone), altered blink reflex on glabella tapping (the forehead between the eyebrows), and postural instability (demonstrated by a pull-from-behind test) gained a place within the definition and diagnosis of the condition.⁷⁷

Such has been the rate of change in clinical conceptualization of the malady over the past two hundred years that only two cardinal signs in the Essay coincide with present-day criteria for the diagnosis of Parkinson’s disease: “tremor at rest” and the postural-gait disorder. The Essay displayed little preference for “tremor at rest” over “trembling” or “agitations” of “an affected body part” as specific descriptors of the shaking, which Parkinson qualified on six occasions with the phrase “when supported,” whereas “tremor at rest” he employed as a phrase only twice.⁷⁸ Today, “tremor at rest” is a more discrete, less contextualized notion than Parkinson’s “shaking,” allied as it was to “tremulousness,” “agitation,” or “vibration” “when supported.” Tremor at rest today suggests a pure motor disorder, whereas for Parkinson it retained a stronger semantic affiliation to older discourses associated with states of anxiety, overexertion, and old age. The Essay’s notion of tremor and the modern conception of “tremor at rest” may not therefore be identical.

Parkinson’s pathognomonic marks of the Shaking are compounds of movement featured in his definition: first, “[i]nvoluntary tremulous motion, with lessened voluntary muscular power, in parts, not in action, and even when supported,” and, second, “a propensity to bend the trunk forwards, and to pass from a walking to a running pace.” Isolating from the latter the tendency to falls—another of the cardinal signs of the condition recognized today—highlights contemporary medicine’s predilection to sever connections with contexts and to focus instead on isolated losses of function.

Although gradual onset and slow development pervade the Essay’s clinical phenomenology, Parkinson failed to pinpoint slowness of initiation of movement, bradykinesia, as a major component of the malady. Today bradykinesia refers to reduced scale of movement, a reduction in amplitude and in what is called sequence effect (a progressive decrement of amplitude and speed on finger tapping).⁷⁹ Without clinical examination—and there is little evidence Parkinson touched any of the patients in his “illustrative cases”—these features of the condition could not have been visible to him.⁸⁰ Nevertheless, Case V suggests Parkinson had indeed observed complete inability to initiate forward movement walking.

Conclusion

Parkinson moved fluently across activities such as noticing, imaging, questioning, and writing, which enabled him to chart the evolving situations and points of view of sufferers from a malady with a long time course. His ability simultaneously to observe a situation from the perspective of sufferer and carer helped generate a rich and varied clinical phenomenology, one whose accuracy and detail allows us to appreciate the Essay as a highly disciplined inquiry. The “History” and the ensemble of cases that Parkinson set out are characterized with exactitude but without adopting a completely “detached” form of objectivity.⁸¹ That he “lamented” the man in Case V, a complete stranger he had observed only from afar, indicates that Parkinson both understood and felt for the man’s predicament, and wove such sentiment into his account, an account whose literary characteristics, in reflecting feeling, worked persuasively on readers. His Essay created the ideal profile of a disease-type, a generalized narrative of the malady, in sufficient phenomenological detail as to enable subsequent clinical investigators to confirm and extend many of his findings. That the malady can be understood as a complex, evolving trajectory of a single “species of disease” Parkinson discerned from his Hoxton practice and its environs, by synthesizing materials from several observational fields within a genre that blended the clinical and the sentimental, creating a convincing medical profile in an affecting narrative.

The disease he described is clearly recognizable today, although some of its clinical details have been supplanted by new findings. As a clinician’s narrative of profound human deterioration inflicted by disease, James Parkinson’s Essay retains a pungency undiminished by time, which registers the human predicaments of those who suffer from the malady and of those who witness it.

Biography

Brian Hurwitz is Professor of Medicine and the Arts at King’s College London where he directs the Centre for the Humanities and Health, which is funded by the Wellcome Trust. The Centre is a multidisciplinary research unit offering training at masters, PhD, MD and postdoctoral levels (http://www.kcl.ac.uk/innovation/groups/chh/index.aspx). He has worked as a family doctor in central London for 30 years, and his research interests include narrative studies in relation to medical practice, ethics, law and the logic and literary shape of clinical case reports. Prior to his current position he was Professor of Primary Health at Imperial College London.