L-Dopa in the Treatment of Parkinsonism A Preliminary Appraisal

HE treatment of parkinsonism from the time of its first clear description by Parkinson 1~ to the modern era has been less than satisfactory. Neurosurgical procedures directed at the pyramidal tracts ranged from the premotor cortex through the cerebral peduncles and into the spinal cord. The goal was to relieve unilaterally a single troublesome symptom, namely, tremor, leaving the problems of bradykinesia, gait, balance, posture, voice, speech, swallowing, and others untouched. Some success was obtained, usually at the price of significant weakness in the limbs involved. When the weakness diminished, as it often did following surgery, the tremor tended to recur. Neurosurgical procedures directed at the basal ganglia ushered in a whole new phase of treatment, chiefly because relief of tremor, rigidity, and poor alternating movements could be obtained without producing any weakness whatsoever. This divorced the tremor and rigidity from what had previously been thought to be their intrinsic dependence upon the great voluntary motor pathway, the pyramidal tract. Reports from neurosurgical centers throughout the world concurred on this point. Our own experiences have been extensively reported and show that alleviation of tremor and rigidity can be obtained in 85% to 90% of properly selected patients with cryosurgical lesions directed at the ventrolateral and posteroventrolateral nuclei of the contralateral thalamus. ~ Acceptable mortality and morbidity figures were also reported from our clinic in a series of nearly 3000 eases. 11 The mortality in that series of consecutive operations done for parkinsonism