INTERNAL REGULATION PROBLEMS                               11

CONSTIPATION:           Seldom discussed but often experienced
in PD, constipation can be very troublesome. Doctors may
blandly dismiss the complaint with advice to eat more bulk
and fibrous foods, drink more water, exercise more, and so
forth. But the problem arises from weakening or paralysis
in PD of the colon (lower or large intestine). Dopamine
figures in neural control elsewhere than in the brain, and
the autonomous control of muscles in the intestines seems
to be impaired by PD. Neglected constipation may result in
a hard impacted mass called megacolon, that becomes a surgical
emergency. Even when controlled, the transit time of food waste through
the colon may be increased in PD from a few hours to a
day or more. I think for most PWP the alternative is a chemical laxative
every few days, plus a precautionary stool softener.
My doctor advises that the least harmful chemical is bisacodyl (Dulcolax
or other tradenames) which stimulates nerve action in
the colon. A suitable stool softener is docusate (various tradenames),
which inhibits the colon's normal function of
water extraction.

SEXUAL DYSFUNCTION:                  PWP have various kinds of
sexual dysfunction, but it is difficult to separate the effects
of the disease from those of drug medication, indirect
reflection of mental state, and normal aging. Men can
experience painful dystonia in muscle surrounding the prostate gland,
which may or may not be related to PD.

Abnormal Libido:                   Sexual desire, pleasure, or
energy may be either weakened by PD or enhanced by drugs taken
for PD. A small controlled study showed that women with PD experienced
and enjoyed sex less than the normal controls. In anecdotal reports, a
few men getting apomorphine for PD had psychotic increase of libido,
leading to psychological
dependence and need for restraint.

Impotence: I have heard remarks about this effect, but have no specific
data.

MENSTRUAL EFFECTS:              Motor symptoms and fluctuations
are much worsened during the peak of the ovulation cycle. In
one report, acetazolamide (Diamox) dramatically  relieved the effect.

INTERNAL REGULATION PROBLEMS (cont.)                       12

URINARY DYSFUNCTION:                  Normal discharge of urine
requires coordination of muscles at several points along the urinary
tract. Both incontinence and retention (at different
times) may occur, I believe more often in men. An urologist
unaware of a male patient's PD may diagnose a common obstruction due to
precancerous growth in the prostate gland, and strongly
urge a popular surgery called Trans-Urethral Resection of
Prostate (TURP), which not only fails to remedy the problem if
due to PD, but needlessly destroys the sexual function of the prostate.

Incontinence:                 As the effect of PD medication
declines after each dose, the PWP may have an uncontrollable
urge to urinate. Urination therefore tends to synchronize
with the medication schedule.

Retention:               Due to lost coordination of various
muscles under autonomous control, intentional voiding just
prior to the scheduled dose of PD medication may be incomplete. Levodopa
in particular seems to have some effect within a
minute or less, and immediately after a dose the need to
urinate returns.

Color In Urine:           Some PD drugs, including Sinemet,
may as a harmless side effect cause deeper color in urine.

INTERNAL REGULATION PROBLEMS (cont.)                      13

EXUDATIONS:             Among the more annoying symptoms of
autonomous system failure in PD are changes in the body's
normal secretions of the skin and elsewhere. Drooling,
runny nose, excessive or abnormally dark perspiration, oily
skin, sebaceous cysts, and eyelid irritation are all well
known in PD.

Drooling:          This is simply excess salivation, which
may occur either when awake or asleep. It is more noticable
when the patient with reduced autonomous function forgets to swallow.

Runny Nose:        At times the subject's nose may suddenly
"drip like a faucet" a clear watery discharge, with no sign
of a cold or allergic insult, and just as suddenly stop. I
think it might be a peak-dose effect of levodopa.

Sweating:                  This sometimes frightening effect
has been noted in scientific literature as due specifically
to levodopa therapy which has reached the fluctuation stage.
It occurs within a narrow range of plasma dopamine level,
and is said to be abolished by addition of a dopamine
agonist to therapy. Unusual dark-colored perspiration has
also been blamed on levodopa. A possibly interesting
sidelight is that the Sinemet formulation of levodopa in
tap water, which usually contains chlorine as a disinfectant,
will leave a black evaporation residue, but not in distilled
water.

Seborrhea:               Excessive oiliness of the scalp, face,
and neck is common enough to be mentioned in patient handbooks,
although the recommended remedy of an astringent shampoo offers
only short-lived relief.

Dandruff:           Usually a harmless byproduct of oily scalp,
in people with or without PD. You probably can forget the usual
anti-dandruff preparations, and concentrate on the oiliness. I
use Boraxo, a powdered hand soap, instead of shampoo.

Skin Cysts:              The sebaceous glands become clogged by
overactivity, and develop pores containing waxy matter that may
be gently squeezed out. When the outlet is clogged, a solid
benign cyst may form, that may require surgical removal to avoid
possible infection or further growth. More often such cysts on
the hairless part of the scalp are tiny and can be removed by liquid
nitrogen.

Blepharitis:                  When related to seborrhea, called
"seborrheic blepharitis" (irritation of eyelids). With no pain
or sign of infection, eyelids are continually red and swollen,
often accompanied by copious tears and/or solid deposit that
interferes with vision unless frequently removed. Books (and
doctors who read them) advise "no tears" baby shampoo, but
plsin water will do just as well. Note, this condition is just
the opposite of the "dry eye" complaint that results from
inadequate blinking by PD patients.

INTERNAL REGULATION PROBLEMS (cont.)                       14

LOW BLOOD PRESSURE:           Low blood pressure has been cited
in scientific literature as a symptom of PD, and I have heard
it mentioned often by other PWP. In related diseases such as
multiple system atrophy (MSA), orthostatic hypotension (failure
to compensate upon arising from seated or supine position) is
an important diagnostic sign.

PROLACTINEMIA:       The bean-size pituitary gland, situated at
the base of the brain and connected by a stalk of neurons to
the hypothalamus, secretes several important hormones including
prolactin, which stimulates lactation in nursing mothers but
also is present to a degree in men. Prolactin is inhibited in
a feedback loop by dopamine, so one might expect an elevated
prolactin level to accompany the dopamine shortage of PD. The
accepted treatment for prolactinemia is a dopamine agonist such
as bromocriptine (Parlodel). An increased level may also be due
to a pituitary tumor, therefore an MRI scan to rule out that
possibility may be a good idea.

THERMAL CONTROL:          PD affects the perception of ambient
temperature, causing the subject to feel colder or warmer than
warranted by actual conditions, but not the internal body
temperature. However at times one hand or foot may be colder
or warmer than the other.

NAUSEA:       I don't know of nausea caused directly by PD, but
it is a common side effect of numerous PD medications. Levodopa
in particular causes nausea, that may be avoided by addition of
carbidopa. The combination is named Sinemet, after the Latin
"sine emesis", for "no vomiting".

SENSORY DYSFUNCTION                                        15

SENSORY DYSFUNCTION:                Although the effects may be
overshadowed by the more urgent motor symptoms of PD, Virtually
all the senses are impaired. Sensory impairment is very common,
if not universal, among PWP but tends to be ignored, not only
by attending neurologists but also in research projects. Its
importance lies in the evidence that PD definitely affects
parts of the brain other than the basal ganglia.

VISUAL EFFECTS:           Aside from the motor effects already
discussed above, PD affects the optical function of the eyes, sometimes
long before appearance of the skeletal movement
symptoms.

Color Perception:              There are several known kinds of
colorblindness, distinguishable by ingenious neuropsychological
tests. In PD the sensitivity to color is only partly lost, but
it appears early enough for use as a preclinical indicator.

Contrast Perception:           In tests involving a grid with
two different shades of alternating gray bars, PWP definitely
are less sensitive to contrast. This loss may affect driving
ability, where poorly maintained lane-marking stripes or other
visual aids may require a bigger share of the driver's
attention.

TEMPERATURE SENSATION:          PWP may feel colder or warmer
than called for by actual temperature of surroundings. The
effect seems to be more pronounced as the levodopa dosage
interval draws to an end.

MECHANICAL SENSATION:       Numerous common manual tasks that
may need a fine sense of touch in the fingertips, reliable
control of applied force, or kinesthetic sense of position
(as in sewing on a button) are harder for PWP.

SMELL AND TASTE:          These closely related senses are very
commonly impaired in PD. Insensitivity to smell (anosmia) may
be nearly complete, so that even strong odors, such as that of
gasoline, are barely noticed. The PWP may also develop a
preference for strong flavors in food.

TINNITUS:             Neurologists claim there is no connection
with PD, but I'm not sure. In my own case, tinnitus in the form
of a loud, very high-pitched whistle has persisted 24 hours a
day since about the time I was diagnosed with PD. Hearing
sensitivity is about normal for my age, 76: high-frequency
(in the range of the tinnitus) loss is pronounced.

Cheers,
Joe
--
J. R. Bruman   (818) 789-3694
3527 Cody Road
Sherman Oaks, CA 91403-5013