L-DOPA, despite my misgivings, on June 18, 1969. The following is an extract from my diary.
25 June.
The first therapeutic responses have already occurred, even though the dosage has only been raised to 1.5 gm. a day. Miss R. has experienced two entire days unprecedentedly free of oculogyric crises, and her eyes, so still and preoccupied before, are brighter and more mobile and attentive to her surroundings.
1 July.
Very real improvements are evident by this date: Miss R. is able to walk unaided down the passage, shows a distinct reduction of rigidity in the left arm and elsewhere, and has become able to speak at a normal conversational volume. Her mood is cheerful, and she has had no oculogyric crises for three days. In view of this propitious response, and the absence of any adverse effects, I am increasing the dosage of L-DOPA to 4 gm. daily.
6 July. Now receiving 4 gm. L-DOPA. Miss R. has continued to improve in almost every way. When I saw her at lunchtime, she was delighted with everything: âDr. Sacks!â she called out, âI walked to and from the new building todayâ (this is a distance of about six hundred yards). âItâs fabulous, itâs gorgeous!â Miss R. has now been free from oculogyric crises for eight days, and has shown no akathisia or undue excitement. I too feel delighted at her progress, but for some reason am conscious of obscure forebodings.
7 July.
Today Miss R. has shown her first signs of unstable and abrupt responses to L-DOPA. Seeing her 3½ hours after her early-morning dose, I was shocked to find her very âdownââhypophonic, somewhat depressed, rigid and akinetic, with extremely small pupils and profuse salivation. Fifteen minutes after receiving her medication she was âupâ againâher voice and walking fully restored, cheerful, smiling, talkative, her eyes alert and shining, and her pupils somewhat dilated. I was further disquieted by observing an occasional impulsion to run, although this was easily checked by her.
8 July.
Following an insomniac night (âI didnât feel in the least sleepy: thoughts just kept rushing through my headâ), Miss R. is extremely active, cheerful, and affectionate. She seems to be very busy, constantly flying from one place to another, and all her thoughts too are concerned with movement; âDr. Sacks,â she exclaimed breathlessly, âI feel great today. I feel I want to fly. I love you, Dr. Sacks, I love you, I love you. You know, youâre the kindest doctor in the world. . . . You know I always liked to travel around: I used to fly to Pittsburgh, Chicago, Miami, California. . . .â etc. Her skin is warm and flushed, her pupils are again very widely dilated, and her eyes constantly glancing to and fro. Her energy seems limitless and untiring, although I get the impression of exhaustion somewhere beneath the pressured surface. An entirely new symptom has also appeared today, a sudden quick movement of the right hand to the chin, which is repeated two or three times an hour. When I questioned Miss R. about this she said: âItâs new, itâs odd, itâs strange, I never did it before. God knows why I do it. I just suddenly get an
urge,
like you suddenly got to sneeze or scratch yourself.â Fearing the onset of akathisia or excessive emotional excitement, I have reduced the dosage of L-DOPA to 3 gm. daily.
9 July.
Today Miss R.âs energy and excitement are unabated, but her mood has veered from elation to anxiety. She is impatient, touchy, and extremely demanding. She became much agitated in the middle of the day, asserting that seven dresses had been stolen from her closet, and that her purse had been stolen. She entertained dark suspicions of various fellow patients: no doubt they had been plotting this for weeks before. Later in the day, she discovered that her dresses were in fact in her closet in their usual position. Her paranoid recriminations
25 June.
The first therapeutic responses have already occurred, even though the dosage has only been raised to 1.5 gm. a day. Miss R. has experienced two entire days unprecedentedly free of oculogyric crises, and her eyes, so still and preoccupied before, are brighter and more mobile and attentive to her surroundings.
1 July.
Very real improvements are evident by this date: Miss R. is able to walk unaided down the passage, shows a distinct reduction of rigidity in the left arm and elsewhere, and has become able to speak at a normal conversational volume. Her mood is cheerful, and she has had no oculogyric crises for three days. In view of this propitious response, and the absence of any adverse effects, I am increasing the dosage of L-DOPA to 4 gm. daily.
6 July. Now receiving 4 gm. L-DOPA. Miss R. has continued to improve in almost every way. When I saw her at lunchtime, she was delighted with everything: âDr. Sacks!â she called out, âI walked to and from the new building todayâ (this is a distance of about six hundred yards). âItâs fabulous, itâs gorgeous!â Miss R. has now been free from oculogyric crises for eight days, and has shown no akathisia or undue excitement. I too feel delighted at her progress, but for some reason am conscious of obscure forebodings.
7 July.
Today Miss R. has shown her first signs of unstable and abrupt responses to L-DOPA. Seeing her 3½ hours after her early-morning dose, I was shocked to find her very âdownââhypophonic, somewhat depressed, rigid and akinetic, with extremely small pupils and profuse salivation. Fifteen minutes after receiving her medication she was âupâ againâher voice and walking fully restored, cheerful, smiling, talkative, her eyes alert and shining, and her pupils somewhat dilated. I was further disquieted by observing an occasional impulsion to run, although this was easily checked by her.
8 July.
Following an insomniac night (âI didnât feel in the least sleepy: thoughts just kept rushing through my headâ), Miss R. is extremely active, cheerful, and affectionate. She seems to be very busy, constantly flying from one place to another, and all her thoughts too are concerned with movement; âDr. Sacks,â she exclaimed breathlessly, âI feel great today. I feel I want to fly. I love you, Dr. Sacks, I love you, I love you. You know, youâre the kindest doctor in the world. . . . You know I always liked to travel around: I used to fly to Pittsburgh, Chicago, Miami, California. . . .â etc. Her skin is warm and flushed, her pupils are again very widely dilated, and her eyes constantly glancing to and fro. Her energy seems limitless and untiring, although I get the impression of exhaustion somewhere beneath the pressured surface. An entirely new symptom has also appeared today, a sudden quick movement of the right hand to the chin, which is repeated two or three times an hour. When I questioned Miss R. about this she said: âItâs new, itâs odd, itâs strange, I never did it before. God knows why I do it. I just suddenly get an
urge,
like you suddenly got to sneeze or scratch yourself.â Fearing the onset of akathisia or excessive emotional excitement, I have reduced the dosage of L-DOPA to 3 gm. daily.
9 July.
Today Miss R.âs energy and excitement are unabated, but her mood has veered from elation to anxiety. She is impatient, touchy, and extremely demanding. She became much agitated in the middle of the day, asserting that seven dresses had been stolen from her closet, and that her purse had been stolen. She entertained dark suspicions of various fellow patients: no doubt they had been plotting this for weeks before. Later in the day, she discovered that her dresses were in fact in her closet in their usual position. Her paranoid recriminations
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