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+Project Gutenberg's An Essay on the Shaking Palsy, by James Parkinson
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
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+
+Title: An Essay on the Shaking Palsy
+
+Author: James Parkinson
+
+Release Date: December 9, 2007 [EBook #23777]
+
+Language: English
+
+Character set encoding: UTF-8
+
+*** START OF THIS PROJECT GUTENBERG EBOOK AN ESSAY ON THE SHAKING PALSY ***
+
+
+
+
+Produced by Irma Spehar and the Online Distributed
+Proofreading Team at http://www.pgdp.net
+
+
+
+
+
+                    AN ESSAY ON THE SHAKING PALSY.
+
+                                  BY
+
+                          _JAMES PARKINSON,_
+
+               MEMBER OF THE ROYAL COLLEGE OF SURGEONS.
+
+                               _LONDON:_
+
+                  PRINTED BY WHITTINGHAM AND ROWLAND,
+
+                           _Goswell Street,_
+
+                    FOR SHERWOOD, NEELY, AND JONES,
+
+                           PATERNOSTER ROW.
+
+                                 1817.
+
+
+
+
+                               PREFACE.
+
+
+The advantages which have been derived from the caution with which
+hypothetical statements are admitted, are in no instance more obvious
+than in those sciences which more particularly belong to the healing
+art. It therefore is necessary, that some conciliatory explanation
+should be offered for the present publication: in which, it is
+acknowledged, that mere conjecture takes the place of experiment; and,
+that analogy is the substitute for anatomical examination, the only
+sure foundation for pathological knowledge.
+
+When, however, the nature of the subject, and the circumstances under
+which it has been here taken up, are considered, it is hoped that the
+offering of the following pages to the attention of the medical
+public, will not be severely censured. The disease, respecting which
+the present inquiry is made, is of a nature highly afflictive.
+Notwithstanding which, it has not yet obtained a place in the
+classification of nosologists; some have regarded its characteristic
+symptoms as distinct and different diseases, and others have given its
+name to diseases differing essentially from it; whilst the unhappy
+sufferer has considered it as an evil, from the domination of which he
+had no prospect of escape.
+
+The disease is of long duration: 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.
+Of both these advantages the writer has had the opportunities of
+availing himself; and has hence been led particularly to observe
+several other cases in which the disease existed in different stages
+of its progress. By these repeated observations, he hoped that he had
+been led to a probable conjecture as to the nature of the malady, and
+that analogy had suggested such means as might be productive of
+relief, and perhaps even of cure, if employed before the disease had
+been too long established. He therefore considered it to be a duty to
+submit his opinions to the examination of others, even in their
+present state of immaturity and imperfection.
+
+To delay their publication did not, indeed, appear to be warrantable.
+The disease had escaped particular notice; and the task of
+ascertaining its nature and cause by anatomical investigation, did not
+seem likely to be taken up by those who, from their abilities and
+opportunities, were most likely to accomplish it. That these friends
+to humanity and medical science, who have already unveiled to us many
+of the morbid processes by which health and life is abridged, might be
+excited to extend their researches to this malady, was much desired;
+and it was hoped, that this might be procured by the publication of
+these remarks.
+
+Should the necessary information be thus obtained, the writer will
+repine at no censure which the precipitate publication of mere
+conjectural suggestions may incur; but shall think himself fully
+rewarded by having excited the attention of those, who may point out
+the most appropriate means of relieving a tedious and most distressing
+malady.
+
+
+
+
+                               CONTENTS.
+
+
+        CHAP. I.
+                                                             PAGE
+DEFINITION—HISTORY—ILLUSTRATIVE CASES                          1
+
+        CHAP. II.
+
+PATHOGNOMONIC SYMPTOMS EXAMINED—TREMOR
+COACTUS—SCELOTYRBE FESTINANS                                  19
+
+        CHAP. III.
+
+SHAKING PALSY DISTINGUISHED FROM OTHER DISEASES
+WITH WHICH IT MAY BE CONFOUNDED                               27
+
+        CHAP. IV.
+
+PROXIMATE CAUSE—REMOTE CAUSES—ILLUSTRATIVE
+CASES                                                         33
+
+        CHAP. V.
+
+CONSIDERATIONS RESPECTING THE MEANS OF CURE                   56
+
+
+
+
+                    AN ESSAY ON THE SHAKING PALSY.
+
+
+
+
+                              CHAPTER I.
+
+               DEFINITION—HISTORY—ILLUSTRATIVE CASES.
+
+
+                 SHAKING PALSY. (_Paralysis Agitans._)
+
+     Involuntary tremulous motion, with lessened muscular 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.
+
+The term Shaking Palsy has been vaguely employed by medical writers in
+general. By some it has been used to designate ordinary cases of
+Palsy, in which some slight tremblings have occurred; whilst by others
+it has been applied to certain anomalous affections, not belonging to
+Palsy.
+
+The shaking of the limbs belonging to this disease was particularly
+noticed, as will be seen when treating of the symptoms, by Galen, who
+marked its peculiar character by an appropriate term. The same
+symptom, it will also be seen, was accurately treated of by Sylvius de
+la Boë. Juncker also seems to have referred to this symptom: having
+divided tremor into active and passive, he says of the latter, “ad
+affectus semiparalyticos pertinent; de qualibus hic agimus, quique
+_tremores paralytoidei_ vocantur.” Tremor has been adopted, as a
+genus, by almost every nosologist; but always unmarked, in their
+several definitions, by such characters as would embrace this disease.
+The celebrated Cullen, with his accustomed accuracy observes,
+“Tremorem, utpote semper symptomaticum, in numerum generum recipere
+nollem; species autem a Sauvagesio recensitas, prout mihi vel astheniæ
+vel paralysios, vel convulsionis symptomata esse videntur, his
+subjungam[1].” Tremor can indeed only be considered as a symptom,
+although several species of it must be admitted. In the present
+instance, the agitation produced by the peculiar species of tremor,
+which here occurs, is chosen to furnish the epithet by which this
+species of Palsy, may be distinguished.
+
+    [Footnote 1: Synopsis Nosologiæ Methodicæ.—Tom. ii. p. 195.]
+
+
+                               HISTORY.
+
+So slight and nearly imperceptible are the first inroads of this
+malady, and so extremely slow is its progress, that it rarely happens,
+that the patient can form any recollection of the precise period of
+its commencement. The first symptoms perceived 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.
+These symptoms gradually increase in the part first affected; and at
+an uncertain period, but seldom in less than twelvemonths or more, the
+morbid influence is felt in some other part. Thus assuming one of the
+hands and arms to be first attacked, the other, at this period
+becomes similarly affected. After a few more months the patient is
+found to be less strict than usual in preserving an upright posture:
+this being most observable whilst walking, but sometimes whilst
+sitting or standing. Sometime after the appearance of this symptom,
+and during its slow increase, one of the legs is discovered slightly
+to tremble, and is also found to suffer fatigue sooner than the leg of
+the other side: and in a few months this limb becomes agitated by
+similar tremblings, and suffers a similar loss of power.
+
+Hitherto the patient will have experienced but little inconvenience;
+and befriended by the strong influence of habitual endurance, would
+perhaps seldom think of his being the subject of disease, except when
+reminded of it by the unsteadiness of his hand, whilst writing or
+employing himself in any nicer kind of manipulation. But as the
+disease proceeds, similar employments are accomplished with
+considerable difficulty, the hand failing to answer with exactness to
+the dictates of the will. Walking becomes a task which cannot be
+performed without considerable attention. The legs are not raised to
+that height, or with that promptitude which the will directs, so that
+the utmost care is necessary to prevent frequent falls.
+
+At this period the patient experiences much inconvenience, which
+unhappily is found daily to increase. The submission of the limbs to
+the directions of the will can hardly ever be obtained in the
+performance of the most ordinary offices of life. The fingers cannot
+be disposed of in the proposed directions, and applied with certainty
+to any proposed point. As time and the disease proceed, difficulties
+increase: writing can now be hardly at all accomplished; and reading,
+from the tremulous motion, is accomplished with some difficulty.
+Whilst at meals the fork not being duly directed frequently fails to
+raise the morsel from the plate: which, when seized, is with much
+difficulty conveyed to the mouth. At this period the patient seldom
+experiences a suspension of the agitation of his limbs. Commencing,
+for instance in one arm, the wearisome agitation is borne until
+beyond sufferance, when by suddenly changing the posture it is for a
+time stopped in that limb, to commence, generally, in less than a
+minute in one of the legs, or in the arm of the other side. Harassed
+by this tormenting round, the patient has recourse to walking, a mode
+of exercise to which the sufferers from this malady are in general
+partial; owing to their attention being thereby somewhat diverted from
+their unpleasant feelings, by the care and exertion required to ensure
+its safe performance.
+
+But as the malady proceeds, even this temporary mitigation of
+suffering from the agitation of the limbs is denied. 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, when this state of the malady is
+attained, the patient can no longer exercise himself by walking in his
+usual manner, but is thrown on the toes and forepart of the feet;
+being, at the same time, irresistibly impelled to take much quicker
+and shorter steps, and thereby to adopt unwillingly a running pace. In
+some cases it is found necessary entirely to substitute running for
+walking; since otherwise the patient, on proceeding only a very few
+paces, would inevitably fall.
+
+In this stage, the sleep becomes much disturbed. The tremulous motion
+of the limbs occur during sleep, and augment until they awaken the
+patient, and frequently with much agitation and alarm. 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 of
+very considerable power: the expulsion of the fæces from the rectum
+sometimes requiring mechanical aid. As the disease proceeds towards
+its last stage, the trunk is almost permanently bowed, the muscular
+power is more decidedly diminished, and the tremulous agitation
+becomes violent. The patient walks now with great difficulty, and
+unable any longer to support himself with his stick, he dares not
+venture on this 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. His words are now
+scarcely intelligible; and 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, pharynx, &c. impeded by impaired
+action and perpetual agitation, that the food is with difficulty
+retained in the mouth until masticated; and then as difficultly
+swallowed. Now also, from the same cause, another very unpleasant
+circumstance occurs: the saliva fails of being directed to the back
+part of the fauces, and hence is continually draining from the mouth,
+mixed with the particles of food, which he is no longer able to clear
+from the inside of the mouth.
+
+As the debility increases and the influence of the will over the
+muscles fades away, the tremulous agitation becomes more vehement. It
+now seldom leaves him for a moment; but even when exhausted nature
+seizes a small portion of sleep, the motion becomes so violent as not
+only to shake the bed-hangings, but even the floor and sashes of the
+room. The chin is now almost immoveably 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. The urine and fæces are passed involuntarily; and at the last,
+constant sleepiness, with slight delirium, and other marks of extreme
+exhaustion, announce the wished-for release.
+
+
+                                CASE I.
+
+Almost every circumstance noted in the preceding description, was
+observed in a case which occurred several years back, and which, from
+the particular 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;
+excited an eager wish to acquire some further knowledge of its nature
+and cause.
+
+The subject of this case was a man rather more than fifty years of
+age, who had industriously followed the business of a gardener,
+leading a life of remarkable temperance and sobriety. The commencement
+of the malady was first manifested by a slight trembling of the left
+hand and arm, a circumstance which he was disposed to attribute to his
+having been engaged for several days in a kind of employment requiring
+considerable exertion of that limb. Although repeatedly questioned, he
+could recollect no other circumstance which he could consider as
+having been likely to have occasioned his malady. He had not suffered
+much from Rheumatism, or been subject to pains of the head, or had
+ever experienced any sudden seizure which could be referred to
+apoplexy or hemiplegia. In this case, every circumstance occurred
+which has been mentioned in the preceding history.
+
+
+                               CASE II.
+
+The subject of the case which was next noticed was casually met with
+in the street. It was a man sixty-two years of age; the greater part
+of whose life had been spent as an attendant at a magistrate's office.
+He had suffered from the disease about eight or ten years. All the
+extremities were considerably agitated, the speech was very much
+interrupted, and the body much bowed and shaken. He 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. He described the
+disease as having come on very gradually, and as being, according to
+his full assurance, the consequence of considerable irregularities in
+his mode of living, and particularly of indulgence in spirituous
+liquors. He was the inmate of a poor-house of a distant parish, and
+being fully assured of the incurable nature of his complaint, declined
+making any attempts for relief.
+
+
+                               CASE III.
+
+The next case was also noticed casually in the street. The subject of
+it was a man of about sixty-five years of age, of a remarkable
+athletic frame. The agitation of the limbs, and indeed of the head and
+of the whole body, was too vehement to allow it to be designated as
+trembling. 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. He stated, that he had been a sailor, and
+attributed his complaints to having been for several months confined
+in a Spanish prison, where he had, during the whole period of his
+confinement, lain upon the bare damp earth. The disease had here
+continued so long, and made such a progress, as to afford little or no
+prospect of relief. He besides was a poor mendicant, requiring as well
+as the means of medical experiment, those collateral aids which he
+could only obtain in an hospital. He was therefore recommended to make
+trial if any relief could, in that mode, be yielded him. The poor man,
+however, appeared to be by no means disposed to make the experiment.
+
+
+                               CASE IV.
+
+The next case which presented itself was that of a gentleman about
+fifty-five years, who had first experienced the trembling of the arms
+about five years before. His application was on account of a
+considerable degree of inflammation over the lower ribs on the left
+side, which terminated in the formation of matter beneath the fascia.
+About a pint was removed on making the necessary opening; and a
+considerable quantity discharged daily for two or three weeks. On his
+recovery from this, no change appeared to have taken place in his
+original complaint; and the opportunity of learning its future
+progress was lost by his removal to a distant part of the country.
+
+
+                                CASE V.
+
+In another case, the particulars of which could not be obtained, and
+the gentleman, the lamented subject of which was only seen at a
+distance, one of the characteristic symptoms of this malady, the
+inability for motion, except in a running pace, appeared to exist in
+an extraordinary degree. It seemed to be necessary that the gentleman
+should be supported by his attendant, 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, after his having run about twenty paces.
+
+
+                               CASE VI.
+
+In a case which presented itself to observation since those
+above-mentioned, every information as to the progress of the malady
+was very readily obtained. The gentleman who was the subject of it is
+seventy-two years of age. He has led a life of temperance, and has
+never been exposed to any particular situation or circumstance which
+he can conceive likely to have occasioned, or disposed to this
+complaint; which he rather seems to regard as incidental upon his
+advanced age, than as an object of medical attention. He however
+recollects, that about twenty years ago, he was troubled with
+lumbago, which was severe and lasted some time. About eleven or
+twelve, or perhaps more, years ago, he first perceived weakness in the
+left hand and arm, and soon after found the trembling commence. In
+about three years afterwards the right arm became affected in a
+similar manner: and soon afterwards the convulsive motions affected
+the whole body, and began to interrupt the speech. In about three
+years from that time the legs became affected. Of late years the
+action of the bowels had been very much retarded; and at two or three
+different periods had, with great difficulty, been made to yield to
+the action of very strong cathartics. But within the last twelvemonths
+this difficulty has not been so great; perhaps owing to an increased
+secretion of mucus, which envelopes the passing fæces, and which
+precedes and follows their discharge in considerable quantity.
+
+About a year since, on waking in the night, he found that he had
+nearly lost the use of the right side, and that the face was much
+drawn to the left side. His medical attendant saw him the following
+day, when he found him languid, with a small and quick pulse, and
+without pain in the head or disposition to sleep. Nothing more
+therefore was done than to promote the action of the bowels, and apply
+a blister to the back of the neck, and in about a fortnight the limbs
+had entirely recovered from their palsied state. During the time of
+their having remained in this state, neither the arm nor the leg of
+the paralytic side was in the least affected with the tremulous
+agitation; but as their paralysed state was removed, the shaking
+returned.
+
+At present he is almost constantly troubled with the agitation, which
+he describes as generally commencing in a slight degree, and gradually
+increasing, until it arises to such a height as to shake the room;
+when, by a sudden and somewhat violent change of posture, he is almost
+always able to stop it. But very soon afterwards it will commence in
+some other limb, in a small degree, and gradually increase in
+violence; but he does not remember the thus checking of it, to have
+been followed by any injurious effect. When the agitation had not
+been thus interrupted, he stated, that it gradually extended through
+all the limbs, and at last affected the whole trunk. To illustrate his
+observation as to the power of suspending the motion by a sudden
+change of posture, 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' time.
+
+He now possessed but little power in giving a required direction to
+the motions of any part. He was scarcely able to feed himself. He had
+written hardly intelligibly for the last three years; and at present
+could not write at all. His attendants observed, that of late the
+trembling would sometimes begin in his sleep, and increase until it
+awakened him: when he always was in a state of agitation and alarm.
+
+On 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.
+
+The preceding 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.
+
+
+
+
+                               CHAP. II.
+
+    PATHOGNOMONIC SYMPTOMS EXAMINED—_TREMOR COACTUS_—_SCELOTYRBE
+                              FESTINANS_.
+
+
+It has been seen in the preceding history of the disease, and in the
+accompanying cases, that certain affections, the tremulous agitations,
+and the almost invincible propensity to run, when wishing only to
+walk, each of which has been considered by nosologists as distinct
+diseases, appear to be pathognomonic symptoms of this malady. To
+determine in which of these points of view these affections ought to
+be regarded, an examination into their nature, and an inquiry into the
+opinions of preceding writers respecting them, seem necessary to be
+attempted.
+
+       *       *       *       *       *
+
+I. _Involuntary tremulous motion, with lessened voluntary muscular
+power, in parts, not in action, and even supported._
+
+It is necessary that the peculiar nature of this tremulous motion
+should be ascertained, as well for the sake of giving to it its
+proper designation, as for assisting in forming probable conjectures,
+as to the nature of the malady, which it helps to characterise.
+Tremors were distinguished by Juncker into Active, those proceeding
+from sudden affection of the minds, as terror, anger, &c. and Passive,
+dependant on debilitating causes, such as advanced age, palsy, &c[2].
+But a much more satisfactory and useful distinction is made by Sylvius
+de la Boë into those tremors which are produced by attempts at
+voluntary motion, and those which occur whilst the body is at rest[3].
+Sauvages distinguishes the latter of these species (_Tremor Coactus_)
+by observing, that the tremulous parts leap, and as it were vibrate,
+even when supported: whilst every other tremor, he observes, ceases,
+when the voluntary exertion for moving the limb stops, or the part is
+supported, but returns when we will the limb to move; whence, he says,
+tremor is distinguished from every other kind of spasm[4].
+
+    [Footnote 2: Junckeri conspect. de tremore.]
+
+    [Footnote 3: Sect. V. Ubi autem solito pauciores deferunter
+    ad eadem organa spiritus animales, imperfectæ ac imbecillæ
+    observantur fieri eadem functiones, in motu tremulo et
+    infirmo, nec diu durante, in visu debili, ac mox defatigato,
+    &c.
+
+    Sect. XIX. Inæqualiter, inordinatè, ac præter contraque
+    voluntatem moventur spiritus animales per nervos ad partes
+    mobiles, in motu convulsivo, ac tremore, quassuve membrorum
+    coacto.
+
+    Distinguendus namque his tremor quiescente licet ac
+    decumbente corpore molustus a motu tremulo, de quo dictum.
+    Sect. V. Quique quiescente corpore cessat, eodemque iterum
+    moto repetit.
+
+    Sect. XXV. Coactus tremor debetur animalibus spiritibus
+    inordinatè ac continuo, cum aliquo impetu ad trementium
+    membrorum musculos per nervos propulsis: sive fuerit is
+    universalis, sive particularis, sive corpus fuerit ad huc
+    robustum sive debile, Sylvii de la Boe. Prax. lib. i. cap.
+    xlii.]
+
+    [Footnote 4: Nosolog. Methodic. Auctore Fr. Boissier de
+    Sauvages, Tomi. II. Partis ii. p. 54. 1763.]
+
+A small degree of attention will be sufficient to perceive, that
+Sauvages, by this just distinction, actually separates this kind of
+tremulous motion, and which is the kind peculiar to this disease, from
+the Genus Tremor. In doing this he is fully warranted by the
+observations of Galen on the same subject, as noticed by Van
+Swieten[5]. “Binas has tremoris species[6] Galenus subtiliter
+distinxit, atque etiam diversis nominibus insignivit, tremor enim
+(τϱὁμ &) facultatis corpus moventis et vehentis infirmitate
+oboritur. Quippe nemo, qui artus movere non instituerit tremet.
+Palpitantes autem partes, etiam in quiete fuerint, etiamsi nullum
+illis motum induxeris palpitant. Ideo primam (_posteriorem_) modo
+descriptam tremoris speciem, quando quiescenti homini involuntariis
+illis et alternis motibus agitantur membra, palpitationem (πἁλμον)
+dixit, posteriorem (_primam_) vero, quæ non fit nisi homo conetur
+partes quasdam movere tremorem vocavit.”
+
+    [Footnote 5: Comment, in Herman. Boerhaav. Aphorismos. Tom.
+    ii. p. 181.]
+
+    [Footnote 6: De tremore. Cap. 3 and 4. Chart, Tom. vii. p.
+    200-201.]
+
+Under this authority the term palpitation may be employed to mark
+those morbid motions which chiefly characterise this disease,
+notwithstanding that this term has been anticipated by Sauvages, as
+characteristic of another species of tremor[7]. The separation of
+palpitation of the limbs (_Palmos_ of Galen, _Tremor Coactus_ of de la
+Boë) from tremor, is the more necessary to be insisted on, since the
+distinction may assist in leading to a knowledge of the seat of the
+disease. It is also necessary to bear in mind, that this affection is
+distinguishable from tremor, by the agitation, in the former,
+occurring whilst the affected part is supported and unemployed, and
+being even checked by the adoption of voluntary motion; whilst in the
+latter, the tremor is induced immediately on bringing the parts into
+action. Thus an artist, afflicted with the malady here treated of,
+whilst his hand and arm is palpitating strongly, will seize his
+pencil, and the motions will be suspended, allowing him to use it for
+a short period; but in tremor, if the hand be quite free from the
+affection, should the pen or pencil be taken up, the trembling
+immediately commences.
+
+    [Footnote 7: Sect. XVI. _Tremor palpitans_, Preysinger
+    classis morborum. _Palmos_ Galeni.
+
+    In tremoribus vulgaribus, æqualibus temporum intervallis, non
+    musculus, sed artus ipsemet alternatim attollitur aut
+    deprimitur, aut in oppositas partes it atque redit per minima
+    tamen spatiola; in palpitatione verò sine ullo ordine musculi
+    unius lacertus subito subsilit, nec regulariter continuoque
+    movetur, sed nunc semel aut bis, nunc minimé intra idem
+    tempus subsilit; an causa irritans in sensorio communi, an in
+    musculo ipse palpitante Quærenda sit, ignoramus. _Nosologiæ
+    Methodicæ_, Vol. I. p. 559. 1768.
+
+    But the adoption which Sauvages has made of this term, will
+    not be regarded as an absolute prohibition from the
+    employment of it here; since the _tremor palpitans_ of
+    Sauvages should be considered rather as a palpitation of the
+    muscles, whilst the motion which is so prominent a symptom in
+    this disease, may be considered as a palpitation of the
+    limbs.]
+
+       *       *       *       *       *
+
+II. _A propensity to bend the trunk forwards, and to pass from a
+walking to a running pace._
+
+This affection, which observation seems to authorise the being
+considered as a symptom peculiar to this disease, has been mentioned
+by few nosologists: it appears to have been first noticed by Gaubius,
+who says, “Cases occur in which the muscles duly excited into action
+by the impulse of the will, do then, with an unbidden agility, and
+with an impetus not to be repressed, accelerate their motion, and run
+before the unwilling mind. It is a frequent fault of the muscles
+belonging to speech, nor yet of these alone: I have seen one, who was
+able to run, but not to walk[8].”
+
+    [Footnote 8: Est et ubi musculi, recte quidem ad voluntatis
+    nutum in actum concitati, injussa dein agilitate atque impetu
+    non reprimendo motus suos accelerant, mentemque invitam
+    præcurrunt. Vitium loquelæ musculis frequens, nec his solis
+    tamen proprium: vidi enim, qui currere, non gradi,
+    poterat[A].]
+
+        [Footnote A: Institution, Patholog. Medicinal. Auctore. H. D.
+        Gaubio. 751.]
+
+Sauvages, referring to this symptom, says, another disease which has
+been very rarely seen by authors, appears to be referable to the same
+genus (Scelotyrbe, of which he makes _Chorea sancti viti_ the first
+species); which, he says, “I think cannot be more fitly named than
+hastening or hurrying Scelotyrbe (_Scelotyrbem festinantem, seu
+festiniam_).”
+
+_Scelotyrbe festinans_, he says, is a peculiar species of scelotyrbe,
+in which the patients, whilst wishing to walk in the ordinary mode,
+are forced to run, which has been seen by Carguet and by the
+illustrious Gaubius; a similar affection of the speech, when the
+tongue thus outruns the mind, is termed volubility. Mons. de Sauvages
+attributes this complaint to a want of flexibility in the muscular
+fibres. Hence, he supposes, that the patients make shorter steps, and
+strive with a more than common exertion or impetus to overcome the
+resistance; walking with a quick and hastened step, as if hurried
+along against their will. _Chorea Viti_, he says, attacks the youth
+of both sexes, but this disease only those advanced in years; and
+adds, that it has hitherto happened to him to have seen only two of
+these cases; and that he has nothing to offer respecting them, either
+in theory or practice[9].
+
+    [Footnote 9: Ad idem genus morbi altera species rarissima ab
+    auctoribus prætervisa referenda videtur, quam non aptius
+    nominari posse putem quàm scelotyrbem festinantem, seu
+    festiniam.
+
+    SECT. II. _Scelotyrbe festinans_: est peculiaris scelotyrbes
+    species in qua ægri solito more dum gradi volunt currere
+    coguntur, quod videre est apud D. Carquet, et observavit
+    Leydæ illustr. Gaubius. _Patholog. instit._ 751, et in
+    loquela hæc _volubilitas_ dicitur quâ lingua præcurrit
+    mentem. Video actu mulierem sexagenariam hoc affectam morbo
+    siccitati nervorum tribuendo; laborat enim rheumatismo sicco,
+    seu ab acrimonia sanguinis, dolores nocte a calore
+    recrudescunt, à thermis non sublevantur: ei præscripsi
+    phlebotomiam, et præmissis jusculis ex lactucâ, endiviâ, et
+    collo arietis, lene catharticum, inde vero lacticinia.
+
+    Est affinitas cum scelotyrbe, chorea viti, deest flexibilitas
+    in fibris musculorum; unde motus breves edunt, et conatu seu
+    impetu solito majori, cum resistentiam illam superare
+    nituntur, velut inviti festinant, ac præcipiti seu concitato
+    passu gradiuntur. Chorea viti pueros, puellasve impuberes
+    aggreditur; festinia vero senes, et duos tantum hactenus
+    observare mihi contigit. Quam multos autem videmus morbos,
+    paucissimosque observamus. De theoria et pràxi nihil habeo
+    quod dicam; etenim sola experienta praxin cujusvis morbi
+    determinat, et ex hac pro felici vel infausto successu
+    theoria dein elicienda est. _Nosolog. Methodic._ Auctore, Fr.
+    Boissier de Sauvages. Tomi. II. Part ii. p. 108.]
+
+Having made the necessary inquiries respecting these two affections,
+_Tremor coactum_ of Sylvius de la Boë and of Sauvages, and _Scelotyrbe
+festinans_ of the latter nosologist, which appear to be characteristic
+symptoms of this disease, it becomes necessary, in the next place, to
+endeavour to distinguish this disease from others which may bear a
+resemblance to it in some particular respects.
+
+
+
+
+                              CHAP. III.
+
+ SHAKING PALSY DISTINGUISHED FROM OTHER DISEASES WITH WHICH IT MAY BE
+                              CONFOUNDED.
+
+
+Treating of a disease resulting from an assemblage of symptoms, some
+of which do not appear to have yet engaged the general notice of the
+profession, particular care is required whilst endeavouring to mark
+its diagnostic characters. It is sufficient, in general, to point out
+the characteristic differences which are observable between diseases
+in some respects resembling each other. But in this case more is
+required: it is necessary to show that it is a disease which does not
+accord with any which are marked in the systematic arrangements of
+nosologists; and that the name by which it is here distinguished has
+been hitherto vaguely applied to diseases very different from each
+other, as well as from that to which it is now appropriated.
+
+Palsy, either consequent to compression of the brain, or dependent on
+partial exhaustion of the energy of that organ, may, when the palsied
+limbs become affected with tremulous motions, be confounded with this
+disease. In those cases the abolition or diminution of voluntary
+muscular action takes place suddenly, the sense of feeling being
+sometimes also impaired. But in this disease, the diminution of the
+influence of the will on the muscles comes on with extreme slowness,
+is always accompanied, and even preceded, by agitations of the
+affected parts, and never by a lessened sense of feeling. The dictates
+of the will are even, in the last stages of the disease, conveyed to
+the muscles; and the muscles act on this impulse, but their actions
+are perverted.
+
+Anomalous cases of convulsive affections have been designated by the
+term Shaking Palsy: a term which appears to be improperly applied to
+these cases, independent of the want of accordance between them and
+that disease which has been here denominated Shaking Palsy. Dr.
+Kirkland, in his commentary on Apoplectic and Paralytic Affections,
+&c. cites the following case, related by Dr. Charlton, as belonging,
+he says, to the class of Shaking Palsies. “Mary Ford, of a sanguineous
+and robust constitution, had an involuntary motion of her right arm,
+occasioned by a fright, which first brought on convulsion fits, and
+most excruciating pain in the stomach, which vanished on a sudden, and
+her right arm was instantaneously flung into an involuntary and
+perpetual motion, like the swing of a pendulum, raising the hand, at
+every vibration higher than her head; but if by any means whatever it
+was stopped; the pain in her stomach came on again, and convulsion
+fits were the certain consequence, which went off when the vibration
+of her hand returned.”
+
+Another case, which the Doctor designates as 'A Shaking Palsy,'
+apparently from worms, he describes thus, “A poor boy, about twelve
+or thirteen years of age, was seized with a Shaking Palsy. His legs
+became useless, and together with his head and hands, were in
+continual agitation; after many weeks trial of various remedies, my
+assistance was desired.
+
+“His bowels being cleared, I ordered him a grain of Opium a day in the
+gum pill; and in three or four days the shaking had nearly left him.”
+By pursuing this plan, the medicine proving a vermifuge, he could soon
+walk, and was restored to perfect health.
+
+Whether these cases should be classed under Shaking Palsy or not, is
+necessary to be here determined; since, if they are properly ranked,
+the cases which have been described in the preceding pages, differ so
+much from them as certainly to oppose their being classed together:
+and the disease, which is the subject of these pages, cannot be
+considered as the same with Shaking Palsy, as characterised by those
+cases.
+
+The term Shaking Palsy is evidently inapplicable to the first of these
+cases, which appears to have belonged more properly to the genus
+_Convulsio_, of Cullen, or to _Hieranosos_ of Linnæus and Vogel[10].
+
+    [Footnote 10: Corporis agitatio continua, indolens,
+    convulsiva, cum sensibilitate.—_Linn._
+
+    Agitatio corporis vel artuum convulsiva continua, chronica,
+    cum integritate sensuum.—_Vogel._
+
+    This genus is resolved by Cullen into that of Convulsio.
+    _Synops. Nosol._ 1803.
+
+    Dr. Macbride has given a very interesting and illustrative
+    case of this disease.
+
+    “Hieranasos, or Morbus Sacer, so called, as being vulgarly
+    supposed to arise from witchcraft, or some extraordinary
+    celestial influence, is a distinct genus of disease, though a
+    very uncommon one; the author once had an opportunity of
+    seeing a case. The patient was a lad about seventeen, who at
+    that time had laboured under this extraordinary disease for
+    more than twelve years. His body was so distorted, and the
+    legs and arms so twisted round it, by the continued
+    convulsive working, that no words can give an adequate idea
+    of the oddity of his figure; the agitation of the muscles was
+    perpetual; but in general he did not complain of pain nor
+    sickness; and had his senses perfectly, insomuch that he used
+    to assist his mother, who kept a little school, in teaching
+    children to read.” _A methodical Introduction to the Theory
+    and Practice of Physic. By David Macbride, M.D. p. 559._]
+
+The latter appears to be referable to that class of proteal forms of
+disease, generated by a disordered state of primæ viæ, sympathetically
+affecting the nervous influence in a distant part of the body.
+
+Unless attention is paid to one circumstance, this disease will be
+confounded with those species of passive tremblings to which the term
+Shaking Palsies has frequently been applied. These are, _tremor
+temulentus_, the trembling consequent to indulgence in the drinking of
+spirituous liquors; that which proceeds from the immoderate employment
+of tea and coffee; that which appears to be dependent on advanced age;
+and all those tremblings which proceed from the various circumstances
+which induce a diminution of power in the nervous system. But by
+attending to that circumstance alone, which has been already noted as
+characteristic of mere tremor, the distinction will readily be made.
+If the trembling limb be supported, and none of its muscles be called
+into action, the trembling will cease. In the real Shaking Palsy the
+reverse of this takes place, the agitation continues in full force
+whilst the limb is at rest and unemployed; and even is sometimes
+diminished by calling the muscles into employment.
+
+
+
+
+                               CHAP. IV.
+
+          PROXIMATE CAUSE—REMOTE CAUSES—ILLUSTRATIVE CASES.
+
+
+Before making the attempt to point out the nature and cause of this
+disease, it is necessary to plead, that it is made under very
+unfavourable circumstances. Unaided by previous inquiries immediately
+directed to this disease, and not having had the advantage, in a
+single case, of that light which anatomical examination yields,
+opinions and not facts can only be offered. Conjecture founded on
+analogy, and an attentive consideration of the peculiar symptoms of
+the disease, have been the only guides that could be obtained for this
+research, the result of which is, as it ought to be, offered with
+hesitation.
+
+                       SUPPOSED PROXIMATE CAUSE.
+
+     A diseased state of the _medulla spinalis_, in that part
+     which is contained in the canal, formed by the superior
+     cervical vertebræ, and extending, as the disease proceeds,
+     to the _medulla oblongata_.
+
+By the nature of the symptoms we are taught, that the disease depends
+on some irregularity in the direction of the nervous influence; by the
+wide range of parts which are affected, that the injury is rather in
+the source of this influence than merely in the nerves of the parts;
+by the situation of the parts whose actions are impaired, and the
+order in which they become affected, that the proximate cause of the
+disease is in the superior part of the medulla spinalis; and by the
+absence of any injury to the senses and to the intellect, that the
+morbid state does not extend to the encephalon.
+
+Uncertainty existing as to the nature of the proximate cause of this
+disease, its remote causes must necessarily be referred to with
+indecision. Assuming however the state just mentioned as the proximate
+cause, it may be concluded that this may be the result of injuries of
+the medulla itself, or of the theca helping to form the canal in which
+it is inclosed.
+
+The great degree of mobility in that portion of the spine which is
+formed by the superior cervical vertebræ, must render it, and the
+contained parts, liable to injury from sudden distortions. Hence
+therefore may proceed inflammation of quicker or of slower progress,
+disease of the vertebræ, derangement of structure in the medulla, or
+in its membranes, thickening or even ulceration of the theca, effusion
+of fluids, &c.
+
+But in no case which has been noticed, has the patient recollected
+receiving any injury of this kind, or any fixed pain in early life in
+these parts, which might have led to the opinion that the foundation
+for this malady had been thus laid. On the subject indeed of remote
+causes, no satisfactory accounts has yet been obtained from any of the
+sufferers. Whilst one has attributed this affliction to indulgence in
+spirituous liquors, and another to long lying on the damp ground; the
+others have been unable to suggest any circumstance whatever, which,
+in their opinion, could be considered as having given origin, or
+disposed, to the calamity under which they suffered.
+
+Cases illustrative of the nature and cause of this malady are very
+rare. In the following case symptoms very similar are observable, so
+far as affecting the lower extremities. That the medulla spinalis was
+here affected, and in its lower part, is not to be doubted: but this,
+unfortunately, was never ascertained by examination. It must be
+however remarked, that this case differed from those which have been
+given of this disease, in the suddenness with which the symptoms
+appeared.
+
+_A. B._ aged twenty-six years, during a course of mercury for a
+venereal affection, was exposed to severely inclement weather, for
+several hours, and the next morning, complained of extreme pain in the
+back, and of total inability to employ voluntarily the muscles of the
+lower extremities, which were continually agitated with severe
+convulsive motions. The physician who attended him employed those
+means which seemed best calculated to relieve him; but with no
+beneficial effect. The lower extremities were perpetually agitated
+with strong palpitatory motions, and, frequently, three or four times
+in a minute, suddenly raised with great vehemence two or three feet
+from the ground, either in a forward or oblique direction, striking
+one limb against the other, or against the chairs, tables, or any
+substance which stood in the way. To check these inordinate motions,
+no means were in the least effectual, except striking the thighs
+forcibly during the more violent convulsions. No advantage was derived
+from all the means which were employed during upwards of twelvemonths.
+Full ten years after this period, the unhappy subject of this malady
+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.
+
+It must be acknowledged, that in the well-known cases, described by
+Mr. Potts, of that kind of Palsy of the lower limbs which is
+frequently found to accompany a curvature of the spine, and in which a
+carious state of the vertebræ is found to exist, no instructive
+analogy is discoverable; slight convulsive motions may indeed happen
+in the disease proceeding from curvature of the spine; but palpitating
+motions of the limbs, such as belong to the disease here described, do
+not appear to have been hitherto noticed.
+
+Whilst striving to determine the nature and origin of this disease, it
+becomes necessary to give the following particulars of an interesting
+case of Palsy occasioned by a fall, attended with uncommon symptoms,
+related by Dr. Maty, in the third volume of the Medical Observations
+and Inquiries. The subject of this case, the Count de Lordat, had the
+misfortune to be overturned from a pretty high and steep bank. His
+head pitched against the top of the coach, and was bent from left to
+right; his left shoulder, arm, and especially his hand, were
+considerably bruised. At first he felt a good deal of pain along the
+left side of his neck, but neither then, nor at any other time, had he
+any faintings, vomitings, or giddiness.—On the sixth day he was let
+blood, on account of the pain in his shoulder and the contusion of his
+hand, which were then the only symptoms he complained of, and of
+which he soon found himself relieved.—Towards the beginning of the
+following winter, he began to find _a small impediment in uttering
+some words, and his left arm appeared weaker_. In the following
+spring, having suffered considerably from the severities of the winter
+campaign, he found _the difficulty in speaking, and in moving his left
+arm, considerably increased_.—On employing the thermal waters of
+Bourbonne, his speech become freer, but, on his return to Paris, the
+Palsy was increased, and the arm somewhat wasted.—In the beginning of
+the next spring he went to Balaruc; when he became affected with
+_involuntary convulsive motions all over the body_. The left arm
+withered more and more, _a spitting began_, and now it was _with
+difficulty that he uttered a few words_. Frictions and sinapisms were
+successively tried, and an issue, made by a caustic, was kept open for
+some time without any effect; but no mention is made of what part the
+issue was established in.
+
+Soon after this, and three years and a half after the fall, Doctor
+Maty first saw the patient, and gives the following description of
+his situation. “A more melancholy object I never beheld. The patient,
+naturally a handsome, middle-sized, sanguine man, of a cheerful
+disposition, and an active mind, appeared much emaciated, stooping,
+and dejected. _He still walked alone with a cane, from one room to the
+other, but with great difficulty, and in a tottering manner_; his left
+hand and arm were much reduced, and would hardly perform any motion;
+_the right was somewhat benumbed, and he could scarcely lift it up to
+his head; his saliva was continually trickling out of his mouth, and
+he had neither the power of retaining it, nor of spitting it out
+freely_. What words he still could utter were monosyllables, and these
+came out, after much struggle, in a violent expiration, and with such
+a low voice and indistinct articulation, as hardly to be understood
+but by those who were constantly with him. He fetched his breath
+rather hard; his pulse was low, but neither accelerated nor
+intermitting. He took very little nourishment, could chew and swallow
+no solids, and even found great pain in getting down liquids. Milk was
+almost his only food; his body was rather loose, his urine natural,
+his sleep good, his senses, and the powers of his mind, unimpaired; he
+was attentive to, and sensible of every thing which was said in
+conversation, and shewed himself very desirous of joining in it; but
+was continually checked by the impediment in his speech, and the
+difficulty which his hearers were put to. Happily for him he was able
+to read, and as capable as ever of writing, as he shewed me, by
+putting into my hands an account of his present situation, drawn up by
+himself: and I am informed that he spent his time to the very last, in
+writing upon some of the most abstruse subjects.”
+
+This gentleman died about four years after the accident, when the body
+was examined by Dr. Bellett and Mons. Sorbier, who made the following
+report:
+
+“We first examined the muscles of the tongue, which were found
+extenuated and of a loose texture. We observed no signs of compression
+in the lingual and brachial nerves, as high as their exit from the
+basis of the cranium and the vertebræ of the neck; but they appeared
+to us more compact than they commonly are, being nearly tendinous. The
+dura mater was in a sound state, but the pia mater was full of blood
+and lymph; on it several hydatids, and towards the falx some marks of
+suppuration were observed. The ventricles were filled with water, and
+the plexus choroides was considerably enlarged, and stuffed with
+grumous blood. The cortical surface of the brain appeared much browner
+than usual, but neither the medullary part nor cerebellum were
+impaired. We chiefly took notice of the Medulla Oblongata, this was
+greatly enlarged, surpassing the usual size by more than one third. It
+was likewise more compact. The membranes, which, in their
+continuation, inclose the spinal marrow, were so tough that we found
+great difficulty in cutting through them, and we observed this to be
+the cause of the tendinous texture of the cervical nerves. The marrow
+itself had acquired such solidity as to elude the pressure of our
+fingers, it resisted as a callous body, and could not be bruised. This
+hardness was observed all along the vertebræ of the neck, but lessened
+by degrees, and was not near so considerable in the vertebræ of the
+thorax. Though the patient was but nine and thirty years old, the
+cartilages of the sternum were ossified, and required as much labour
+to cut them asunder as the ribs; like these they were spungy, but
+somewhat whiter. The lungs and heart were sound. At the bottom of the
+stomach appeared an inflammation, which increased as it extended to
+the intestines. The ileum looked of that dark and livid hue, which is
+observed in membranous parts tending to mortification. The colon was
+not above an inch in diameter, the rectum was smaller still, but both
+appeared sound.—From these appearances, we were at no loss to fix the
+cause of this gradual palsy in the alteration of the medulla spinalis
+and oblongata.”
+
+Dr. Bellett offers the following explanation of these changes. “I
+conceive, that, by this accident, the head being violently bent to the
+right, the nervous membranes on the left were excessively stretched
+and irritated; that this cause extended by degrees to the spinal
+marrow, which being thereby compressed, brought on the paralytic
+symptoms, not only of the left arm, but at last in some measure also
+of the right. This induration seems to have been occasioned by the
+constant afflux of the nutritive juices, which were stopt at that
+place, and deprived of their most liquid parts; the grosser ones being
+unable to spread in the boney cavity, by which they were confined,
+could only acquire a greater solidity, and change a soft body into a
+hard and nearly osseous mass. This likewise accounts for the increase
+of the medulla oblongata, which being loaded with more juices than it
+could send off, swelled in the same manner as the branches of trees,
+which will grow of a monstrous size, when the sap that runs into them
+is stopt in its progress. The medulla oblongata not growing so hard as
+the spinalis, was doubtless owing to its not being confined in an
+osseous theca, but surrounded with soft parts, which allowed it room
+to spread. The obstruction from the bulk of this substance must have
+affected the brain, and probably induced the thickening of the pia
+mater, the hydatids, and the beginning of suppuration, whereas the
+dura mater, being of a harder texture, was not injured[11].”
+
+    [Footnote 11: Medical Observations and Inquiries, Vol. III.
+    p. 257.]
+
+In some of the symptoms which appeared in this case, an agreement is
+observable between it and those cases which are mentioned in the
+beginning of these pages. The weakened state of both arms; the power
+first lessening in one arm, and then in a similar manner in the other
+arm; the affection of the speech; the difficulty in chewing and in
+swallowing; as well as of retaining, or freely discharging, the
+spittle; the convulsive motions of the body; and the unimpaired state
+of the intellects; constitute such a degree of accordance as, although
+it may not mark an identity of disease, serves at least to show that
+nearly the same parts were the seat of the disease in both instances.
+Thus we attain something like confirmation of the supposed proximate
+cause, and of one of the assumed occasional causes.
+
+Whilst conjecturing as to the cause of this disease, the following
+collected observations on the effects of injury to the medulla
+spinalis, by Sir Everard Home, become particularly deserving of
+attention. It thence appears, that none of the characteristic symptoms
+of this malady are produced by compression, laceration, or complete
+division of the medulla spinalis.
+
+“Pressure upon the medulla spinalis of the neck, by coagulated blood,
+produced paralytic affections of the arms and legs; all the functions
+of the internal organs were carried on for thirty-five days, but the
+urine and stools passed involuntarily[12].
+
+    [Footnote 12: A coagulum of blood, the thickness of a
+    crown-piece, was found lying upon the external surface of the
+    dura-matral covering of the medulla spinalis, extending from
+    the fourth vertebra colli to the second vertebra dorsi. The
+    medulla spinalis itself was uninjured.]
+
+“Blood extravasated in the central part of the medulla, in the neck,
+was attended with paralytic affection of the legs, but not of the
+arms[13].
+
+    [Footnote 13: The sixth and seventh vertebra colli were
+    dislocated, the medulla spinalis, externally, was uninjured;
+    but in the centre of its substance, just at that part, there
+    was a coagulum of blood nearly two inches in length.]
+
+“In a case where the substance of the medulla was lacerated in the
+neck, there was a paralysis in all the parts below the laceration, the
+lining of the œsophagus was so sensible, that solids could not be
+swallowed, on account of the pain they occasioned[14].
+
+    [Footnote 14: The seventh vertebra colli was fractured, and
+    the medulla spinalis passing through it, was lacerated and
+    compressed.]
+
+“When the medulla of the back was completely divided, there was
+momentary loss of sight, loss of memory for fifteen minutes, and
+permanent insensibility in all the lower parts of the body. The skin
+above the division of the spinal marrow perspired, that below did not.
+The wounded spinal marrow appeared to be extremely sensible[15].”
+_Philosophical Transactions_, 1816, p. 485.
+
+    [Footnote 15: The spinal marrow, within the canal of the
+    sixth vertebra dorsi, was completely destroyed by a musket
+    ball. The person lived four days.]
+
+In two of the cases already noticed, symptoms of rheumatism had
+previously existed; and in Case IV. the right arm, in which the
+palpitation began, was said to have been very violently affected with
+rheumatic pain to the fingers ends. The consideration of this case, in
+which the palpitation had been preceded, at a considerable distance of
+time, by this painful affection of the arm, led to the supposition
+that this latter circumstance might be the cause of the palpitations,
+and the other subsequent symptoms of this disease. This supposition
+naturally occasioned the attention to be eagerly fixed on the
+following case; and of course influenced the mode of treatment which
+was adopted.
+
+_A. B._ subject to rheumatic affection of the deltoid muscle, had felt
+the usual inconveniences from it for two or three days; but at night
+found the pain had extended down the arm, along the inside of the
+fore-arm, and on the sides of the fingers, in which a continual
+tingling was felt. The pain, without being extremely intense, was such
+as effectually to prevent sleep: and seemed to follow the course of
+the brachial nerve. Whilst ascertaining the propriety of this
+conclusion, the pain was found to ramify, as it were, on the fore and
+back part of the chest; and was slightly augmented by drawing a deep
+breath.
+
+These circumstances suggested the probability of slight inflammation,
+or increased determination to the origin of the nerves of these parts,
+and to the neighbouring medulla. On this ground, blood was taken from
+the back part of the neck, by cupping; hot fomentations were applied
+for about the space of an hour, when the upper part of the back of the
+neck was covered with a blister, perspiration was freely induced by
+two or three small doses of antimonials, and the following morning the
+bowels were evacuated by an appropriate dose of calomel. On the
+following day the pains were much diminished, and in the course of
+four or five days were quite removed. The arm and hand felt now more
+than ordinarily heavy, and were evidently much weakened: aching, and
+feeling extremely wearied after the least exertion. The strength of
+the arm was not completely recovered at the end of more than
+twelvemonths; and, after more than twice that time, exertion would
+excite the feeling of painful weariness, but no palpitation or other
+unpleasant symptom has occurred during the five or six years which
+have since passed.
+
+The commencement, progress, and termination of this attack; with the
+success attending the mode of treatment, and the symptoms which
+followed, seem to lead to the conjecture, that the proximate cause of
+the disease, in this case, existed in the medulla spinalis, and that
+it might, if neglected, have gradually resolved itself into that
+disease which is the object of our present inquiry.
+
+Some few months after the occurrence of the preceding case, the writer
+of these lines was called to a female about forty years of age,
+complaining of great pain in both the arms, extending from the
+shoulder to the finger ends. She stated, that she was attacked in the
+same manner as is described in the preceding case, about nine months
+before; that the complaint was considered as rheumatism, and was not
+benefited by any of the medicines which had been employed; but that
+after three or four weeks it gradually amended, leaving both the arms
+and hands in a very weakened and trembling state. From this state they
+were now somewhat recovered; but she was extremely anxious, fearing
+that if the present attack should not be soon checked, she might
+entirely lose the use of her hands and arms.
+
+Instructed by the preceding case, similar means were here recommended.
+Leeches, stimulating fomentations, and a blister, which was made for
+sometime to yield a purulent discharge, were applied over the cervical
+vertebræ; and in the course of a very few days the pain was entirely
+removed. It is regretted that no farther information, as to the
+progress of this case, could be obtained.
+
+On meeting with these two cases, it was thought that it might not be
+improbable that attacks of this kind, considered at the time merely as
+rheumatic affections, might lay the foundation of this lamentable
+disease, which might manifest itself at some distant period, when the
+circumstance in which it had originated, had, perhaps, almost escaped
+the memory. Indeed when it is considered that neither in the ordinary
+cases of Palsy of the lower extremities, proceeding from diseased
+spine, nor in cases of injured medulla from fractured vertebræ, any of
+the peculiar symptoms of this disease are observable, we necessarily
+doubt as to the probability of its being the direct effect of any
+sudden injury. But taking all circumstances into due consideration,
+particularly the very gradual manner in which the disease commences,
+and proceeds in its attacks; as well as the inability to ascribe its
+origin to any more obvious cause, we are led to seek for it in some
+slow morbid change in the structure of the medulla, or its investing
+membranes, or theca, occasioned by simple inflammation, or rheumatic
+or scrophulous affection.
+
+It must be too obvious that the evidence adduced as to the nature of
+the proximate and occasional causes of this disease, is by no means
+conclusive. A reference to the test therefore which will be yielded by
+an examination of some of the more prominent symptoms, especially as
+to their agreement with the supposed proximate cause, is more
+particularly demanded. Satisfied as to the importance of this part of
+the present undertaking, no apology is offered for the extent to which
+the examination is carried on.
+
+If the palpitation and the attendant weakness of the limbs, &c. be
+considered as to the order in which the several parts are attacked, it
+is believed, that some confirmation will be obtained of the opinion
+which has been just offered, respecting the cause, or at least the
+seat, of that change which may be considered as the proximate cause of
+this disease.
+
+One of the arms, in all the cases which have been here mentioned, has
+been the part in which these symptoms have been first noticed; the
+legs, head, and trunk have then become gradually affected, and lastly,
+the muscles of the mouth and fauces have yielded to the morbid
+influence.
+
+The arms, the parts first manifesting disordered action, of course
+direct us, whilst searching for the cause of these changes, to the
+brachial nerves. But finding the mischief extending to other parts,
+not supplied with these, but with other nerves derived from nearly the
+same part of the medulla spinalis, we are of course led to consider
+that portion of the medulla spinalis itself, from which these nerves
+are derived, as the part in which those changes have taken place,
+which constitute the proximate cause of this disease.
+
+From the subsequent affection of the lower extremities, and from the
+failure of power in the muscles of the trunk, such a change in the
+substance of the medulla spinalis may be inferred, as shall have
+considerably interrupted, and interfered with, the extension of the
+nervous influence to those parts, whose nerves are derived from any
+portion of the medulla below the part which has undergone the diseased
+change.
+
+The difficulty in supporting the trunk erect, as well as the
+propensity to the adopting of a hurried pace, is also referable to
+such a diminution of the nervous power in the extensor muscles of the
+head and trunk, as prevents them from performing the offices of
+maintaining the head and body in an erect position.
+
+From the impediment to speech, the difficulty in mastication and
+swallowing, the inability to retain, or freely to eject, the Saliva,
+may with propriety be inferred an extension of the morbid change
+upwards through the medulla spinalis to the medulla oblongata,
+necessarily impairing the powers of the several nerves derived from
+that portion into which the morbid change may have reached. In the
+late occurrence of this set of symptoms, and the extension upwards of
+the diseased state, a very close agreement is observable between this
+disease and that which has been already shown, proved fatal to the
+Count de Lordat. But in this case, the disease doubtlessly became
+differently modified, and its symptoms considerably accelerated, in
+consequence of the magnitude of the injury by which the disease was
+induced.
+
+
+
+
+                               CHAP. V.
+
+             CONSIDERATIONS RESPECTING THE MEANS OF CURE.
+
+
+The inquiries made in the preceding pages yield, it is to be much
+regretted, but little more than evidence of inference: nothing direct
+and satisfactory has been obtained. All that has been ventured to
+assume here, has been that the disease depends on a disordered state
+of that part of the medulla which is contained in the cervical
+vertebræ. But of what nature that morbid change is; and whether
+originating in the medulla itself, in its membranes, or in the
+containing theca, is, at present, the subject of doubt and conjecture.
+But although, at present, uninformed as to the precise nature of the
+disease, still it ought not to be considered as one against which
+there exists no countervailing remedy.
+
+On the contrary, there appears to be sufficient reason for hoping that
+some remedial process may ere long be discovered, by which, at least,
+the progress of the disease may be stopped. It seldom happens that
+the agitation extends beyond the arms within the first two years;
+which period, therefore, if we were disposed to divide the disease
+into stages, might be said to comprise the first stage. In this
+period, it is very probable, that remedial means might be employed
+with success: and even, if unfortunately deferred to a later period,
+they might then arrest the farther progress of the disease, although
+the removing of the effects already produced, might be hardly to be
+expected.
+
+From a review of the changes which had taken place in the case of
+Count de Lordat, it seems as if we were able to trace the order and
+mode in which the morbid changes may proceed in this disease. From any
+occasional cause, the thecal ligament, the membranes, or the medulla
+itself, may pass into the state of simple excitement or irritation,
+which may be gradually succeeded by such a local afflux and
+determination of blood into the minute vessels, as may terminate in
+actual but slow inflammation. The result of this would be a
+thickening of the theca, or membranes, and perhaps an increase in the
+volume of the medulla itself, which would gradually occasion such a
+degree of pressure against the sides of the unyielding canal, as must
+eventually intercept the influence of the brain upon the inferior
+portion of the medullary column, and upon the parts on which the
+nerves of this portion are disposed.
+
+From this review, and assuming that the morbid changes in this disease
+may not be widely dissimilar from those which occurred in the case of
+Count de Lordat, the chance of relief from the proposed mode of
+treatment may appear to be sufficient to warrant its trial.
+
+In such a case then, at whatever period of the disease it might be
+proposed to attempt the cure, blood should be first taken from the
+upper part of the neck, unless contra-i(n)dicated by any particul(ar)
+circumstance. After which vesicatories should be applied to the (sa)me
+part, and a purulent discharge obtained by appropriate use of the
+Sabine Liniment; having recourse to the application of a fresh
+blister, when from the diminution of the discharging surface, pus is
+not secreted in a sufficient quantity. Should the blisters be found
+too inconvenient, or a sufficient quantity of discharge not be
+obtained thereby, an issue of at least an inch and a half in length
+might be established on each side of the vertebral columna, in its
+superior part. These, it is presumed, would be best formed with
+caustic, and kept open with any proper substance[16].
+
+    [Footnote 16: Cork, which has been hitherto neglected,
+    appears to be very appropriate to this purpose. It possesses
+    lightness, softness, elasticity and sufficient firmness; and
+    is also capable of being readily fashioned to any convenient
+    form. The form which it seems would be best adapted to the
+    part, is that of an almond, or of the variety of bean called
+    scarlet bean; but at least an inch and a half in length.]
+
+Could it have been imagined that such considerable benefit: indeed,
+that such astonishing cures, could have been effected by issues in
+cases of Palsy of the lower extremities from diseased spine? although
+satisfied with ascribing those cases to scrofulous action, we are in
+fact as little informed respecting the nature of the affection,
+inducing the carious state of the vertebræ, as we are respecting the
+peculiar change of structure which takes place in this disease.
+Equally uninformed are we also as to the peculiar kind of morbid
+action, which takes place in the ligaments of the joints; as well as
+that which takes place in different instances of deep seated pains and
+affections of the parts contained in the head, thorax, and abdomen,
+and in all which cases the inducing of a purulent discharge in their
+neighbourhood is so frequently productive of a cure. Experiment has
+not indeed been yet employed to prove, but analogy certainly warrants
+the hope, that similar advantages might be derived from the use of the
+means enumerated, in the present disease. It is obvious, that the
+chance of obtaining relief will depend in a great measure on the
+period at which the means are employed. As in every other disease, so
+here, the earlier the remedies are resorted to, the greater will be
+the probability of success. But in this disease there is one
+circumstance which demands particular attention; the long period to
+which it may be extended. One of its peculiar symptoms, Scelotyrbe
+festinans, may not occur until the disease has existed ten or twelve
+years, or more; hence, when looking for the period, within which our
+hopes of remedial aid is to be limited; we may, guided by the slow
+progress of the malady, extend it to a great length, when compared
+with that within which we should be obliged to confine ourselves in
+most other diseases.
+
+But it is much to be apprehended, as in many other cases, that the
+resolution of the patients will seldom be sufficient to enable them to
+persevere through the length of time which the proposed process will
+necessarily require. As slow as is the progress of the disease, so
+slow in all probability must be the period of the return to health. In
+most cases, especially in those in which the disease has been allowed
+to exist long unopposed, it may be found that all that art is capable
+of accomplishing, is that of checking its further progress. Nor will
+this be regarded as a trifle, when, by reference to the history of the
+disease, is seen the train of harassing evils which would be thus
+avoided.
+
+But it seems as if there existed reason for hoping for more. For
+supposing change of structure to have taken place, it is extremely
+probable that this change may be merely increase in mass or volume by
+interstitial addition, the consequence of increased action in the
+minute vessels of the part. In that case, should the instituting of a
+purulent discharge, in a neighbouring part, act in the manner which we
+would presume it may—should it by keeping up a constant discharge,
+not merely alter the determination, but diminish the inordinate action
+of the vessels in the diseased part; and at the same time excite the
+absorbents to such increased action as may remove the added matter;
+there will exist strong ground for hope, that a happy, though slow
+restoration to health, may be obtained.
+
+Until we are better informed respecting the nature of this disease,
+the employment of internal medicines is scarcely warrantable; unless
+analogy should point out some remedy the trial of which rational hope
+might authorize. Particular circumstances indeed must arise in
+different cases, in which the aid of medicine may be demanded: and the
+intelligent will never fail to avail themselves of any opportunity of
+making trial of the influence of mercury, which has in so many
+instances, manifested its power in correcting derangement of
+structure.
+
+The weakened powers of the muscles in the affected parts is so
+prominent a symptom, as to be very liable to mislead the inattentive,
+who may regard the disease as a mere consequence of constitutional
+debility. If this notion be pursued, and tonic medicines, and highly
+nutritious diet be directed, no benefit is likely to be thus obtained;
+since the disease depends not on general weakness, but merely on the
+interruption of the flow of the nervous influence to the affected
+parts.
+
+It is indeed much to be regretted that this malady is generally
+regarded by the sufferers in this point of view, so discouraging to
+the employment of remedial means. Seldom occurring before the age of
+fifty, and frequently yielding but little inconvenience for several
+months, it is generally considered as the irremediable diminution of
+the nervous influence, naturally resulting from declining life; and
+remedies therefore are seldom sought for.
+
+Although unable to trace the connection by which a disordered state of
+the stomach and bowels may induce a morbid action in a part of the
+medulla spinalis, yet taught by the instruction of Mr. Abernethy,
+little hesitation need be employed before we determine on the
+probability of such occurrence. The power, possessed by sympathy, of
+inducing such disordered action in a distant part, and the probability
+of such disordered action producing derangement of structure, can
+hardly be denied. The following Case seems to prove, at least, that
+the mysterious sympathetic influence which so closely simulates the
+forms of other diseases, may induce such symptoms as would seem to
+menace the formation of a disease not unlike to that which we have
+been here treating of.
+
+_A. B._ A man, 54 years of age, of temperate habits and regular state
+of bowels, became gradually affected with slight numbness and
+prickling, with a feeling of weakness in both arms, accompanied by a
+sense of fulness about the shoulders, as if produced by the pressure
+of a strong ligature; and at times a slight trembling of the hands.
+During the night, the fullness, numbness, and prickling were much
+increased. The appetite had been diminished for several weeks; and the
+abdomen, on being examined, felt as though containing considerable
+accumulation.
+
+Before adopting any other measures, and as there appeared to be no
+marks of vascular fulness, it was determined to empty the bowels. This
+was done effectually by moderate doses of calomel, with the occasional
+help of Epsom salts; and in about ten days, by these means alone, the
+complaints were entirely removed.
+
+Before concluding these pages, it may be proper to observe once more,
+that an important object proposed to be obtained by them is, the
+leading of the attention of those who humanely employ anatomical
+examination in detecting the causes and nature of diseases,
+particularly to this malady. By their benevolent labours its real
+nature may be ascertained, and appropriate modes of relief, or even of
+cure, pointed out.
+
+To such researches the healing art is already much indebted for the
+enlargement of its powers of lessening the evils of suffering
+humanity. Little is the public aware of the obligations it owes to
+those who, led by professional ardour, and the dictates of duty, have
+devoted themselves to these pursuits, under circumstances most
+unpleasant and forbidding. Every person of consideration and feeling,
+may judge of the advantages yielded by the philanthropic exertions of
+a HOWARD; but how few can estimate the benefits bestowed on mankind,
+by the labours of a MORGAGNI, HUNTER, or BAILLIE.
+
+
+                                FINIS.
+
+
+
+
+
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+Project Gutenberg's An Essay on the Shaking Palsy, by James Parkinson
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+
+Title: An Essay on the Shaking Palsy
+
+Author: James Parkinson
+
+Release Date: December 9, 2007 [EBook #23777]
+
+Language: English
+
+Character set encoding: ISO-8859-1
+
+*** START OF THIS PROJECT GUTENBERG EBOOK AN ESSAY ON THE SHAKING PALSY ***
+
+
+
+
+Produced by Irma Spehar and the Online Distributed
+Proofreading Team at http://www.pgdp.net
+
+
+
+
+
+                    AN ESSAY ON THE SHAKING PALSY.
+
+                                  BY
+
+                          _JAMES PARKINSON,_
+
+               MEMBER OF THE ROYAL COLLEGE OF SURGEONS.
+
+                               _LONDON:_
+
+                  PRINTED BY WHITTINGHAM AND ROWLAND,
+
+                           _Goswell Street,_
+
+                    FOR SHERWOOD, NEELY, AND JONES,
+
+                           PATERNOSTER ROW.
+
+                                 1817.
+
+
+
+
+                               PREFACE.
+
+
+The advantages which have been derived from the caution with which
+hypothetical statements are admitted, are in no instance more obvious
+than in those sciences which more particularly belong to the healing
+art. It therefore is necessary, that some conciliatory explanation
+should be offered for the present publication: in which, it is
+acknowledged, that mere conjecture takes the place of experiment; and,
+that analogy is the substitute for anatomical examination, the only
+sure foundation for pathological knowledge.
+
+When, however, the nature of the subject, and the circumstances under
+which it has been here taken up, are considered, it is hoped that the
+offering of the following pages to the attention of the medical
+public, will not be severely censured. The disease, respecting which
+the present inquiry is made, is of a nature highly afflictive.
+Notwithstanding which, it has not yet obtained a place in the
+classification of nosologists; some have regarded its characteristic
+symptoms as distinct and different diseases, and others have given its
+name to diseases differing essentially from it; whilst the unhappy
+sufferer has considered it as an evil, from the domination of which he
+had no prospect of escape.
+
+The disease is of long duration: 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.
+Of both these advantages the writer has had the opportunities of
+availing himself; and has hence been led particularly to observe
+several other cases in which the disease existed in different stages
+of its progress. By these repeated observations, he hoped that he had
+been led to a probable conjecture as to the nature of the malady, and
+that analogy had suggested such means as might be productive of
+relief, and perhaps even of cure, if employed before the disease had
+been too long established. He therefore considered it to be a duty to
+submit his opinions to the examination of others, even in their
+present state of immaturity and imperfection.
+
+To delay their publication did not, indeed, appear to be warrantable.
+The disease had escaped particular notice; and the task of
+ascertaining its nature and cause by anatomical investigation, did not
+seem likely to be taken up by those who, from their abilities and
+opportunities, were most likely to accomplish it. That these friends
+to humanity and medical science, who have already unveiled to us many
+of the morbid processes by which health and life is abridged, might be
+excited to extend their researches to this malady, was much desired;
+and it was hoped, that this might be procured by the publication of
+these remarks.
+
+Should the necessary information be thus obtained, the writer will
+repine at no censure which the precipitate publication of mere
+conjectural suggestions may incur; but shall think himself fully
+rewarded by having excited the attention of those, who may point out
+the most appropriate means of relieving a tedious and most distressing
+malady.
+
+
+
+
+                               CONTENTS.
+
+
+        CHAP. I.
+                                                             PAGE
+DEFINITION--HISTORY--ILLUSTRATIVE CASES                        1
+
+        CHAP. II.
+
+PATHOGNOMONIC SYMPTOMS EXAMINED--TREMOR
+COACTUS--SCELOTYRBE FESTINANS                                 19
+
+        CHAP. III.
+
+SHAKING PALSY DISTINGUISHED FROM OTHER DISEASES
+WITH WHICH IT MAY BE CONFOUNDED                               27
+
+        CHAP. IV.
+
+PROXIMATE CAUSE--REMOTE CAUSES--ILLUSTRATIVE
+CASES                                                         33
+
+        CHAP. V.
+
+CONSIDERATIONS RESPECTING THE MEANS OF CURE                   56
+
+
+
+
+                    AN ESSAY ON THE SHAKING PALSY.
+
+
+
+
+                              CHAPTER I.
+
+               DEFINITION--HISTORY--ILLUSTRATIVE CASES.
+
+
+                 SHAKING PALSY. (_Paralysis Agitans._)
+
+     Involuntary tremulous motion, with lessened muscular 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.
+
+The term Shaking Palsy has been vaguely employed by medical writers in
+general. By some it has been used to designate ordinary cases of
+Palsy, in which some slight tremblings have occurred; whilst by others
+it has been applied to certain anomalous affections, not belonging to
+Palsy.
+
+The shaking of the limbs belonging to this disease was particularly
+noticed, as will be seen when treating of the symptoms, by Galen, who
+marked its peculiar character by an appropriate term. The same
+symptom, it will also be seen, was accurately treated of by Sylvius de
+la Bo�. Juncker also seems to have referred to this symptom: having
+divided tremor into active and passive, he says of the latter, "ad
+affectus semiparalyticos pertinent; de qualibus hic agimus, quique
+_tremores paralytoidei_ vocantur." Tremor has been adopted, as a
+genus, by almost every nosologist; but always unmarked, in their
+several definitions, by such characters as would embrace this disease.
+The celebrated Cullen, with his accustomed accuracy observes,
+"Tremorem, utpote semper symptomaticum, in numerum generum recipere
+nollem; species autem a Sauvagesio recensitas, prout mihi vel astheni�
+vel paralysios, vel convulsionis symptomata esse videntur, his
+subjungam[1]." Tremor can indeed only be considered as a symptom,
+although several species of it must be admitted. In the present
+instance, the agitation produced by the peculiar species of tremor,
+which here occurs, is chosen to furnish the epithet by which this
+species of Palsy, may be distinguished.
+
+    [Footnote 1: Synopsis Nosologi� Methodic�.--Tom. ii. p. 195.]
+
+
+                               HISTORY.
+
+So slight and nearly imperceptible are the first inroads of this
+malady, and so extremely slow is its progress, that it rarely happens,
+that the patient can form any recollection of the precise period of
+its commencement. The first symptoms perceived 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.
+These symptoms gradually increase in the part first affected; and at
+an uncertain period, but seldom in less than twelvemonths or more, the
+morbid influence is felt in some other part. Thus assuming one of the
+hands and arms to be first attacked, the other, at this period
+becomes similarly affected. After a few more months the patient is
+found to be less strict than usual in preserving an upright posture:
+this being most observable whilst walking, but sometimes whilst
+sitting or standing. Sometime after the appearance of this symptom,
+and during its slow increase, one of the legs is discovered slightly
+to tremble, and is also found to suffer fatigue sooner than the leg of
+the other side: and in a few months this limb becomes agitated by
+similar tremblings, and suffers a similar loss of power.
+
+Hitherto the patient will have experienced but little inconvenience;
+and befriended by the strong influence of habitual endurance, would
+perhaps seldom think of his being the subject of disease, except when
+reminded of it by the unsteadiness of his hand, whilst writing or
+employing himself in any nicer kind of manipulation. But as the
+disease proceeds, similar employments are accomplished with
+considerable difficulty, the hand failing to answer with exactness to
+the dictates of the will. Walking becomes a task which cannot be
+performed without considerable attention. The legs are not raised to
+that height, or with that promptitude which the will directs, so that
+the utmost care is necessary to prevent frequent falls.
+
+At this period the patient experiences much inconvenience, which
+unhappily is found daily to increase. The submission of the limbs to
+the directions of the will can hardly ever be obtained in the
+performance of the most ordinary offices of life. The fingers cannot
+be disposed of in the proposed directions, and applied with certainty
+to any proposed point. As time and the disease proceed, difficulties
+increase: writing can now be hardly at all accomplished; and reading,
+from the tremulous motion, is accomplished with some difficulty.
+Whilst at meals the fork not being duly directed frequently fails to
+raise the morsel from the plate: which, when seized, is with much
+difficulty conveyed to the mouth. At this period the patient seldom
+experiences a suspension of the agitation of his limbs. Commencing,
+for instance in one arm, the wearisome agitation is borne until
+beyond sufferance, when by suddenly changing the posture it is for a
+time stopped in that limb, to commence, generally, in less than a
+minute in one of the legs, or in the arm of the other side. Harassed
+by this tormenting round, the patient has recourse to walking, a mode
+of exercise to which the sufferers from this malady are in general
+partial; owing to their attention being thereby somewhat diverted from
+their unpleasant feelings, by the care and exertion required to ensure
+its safe performance.
+
+But as the malady proceeds, even this temporary mitigation of
+suffering from the agitation of the limbs is denied. 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, when this state of the malady is
+attained, the patient can no longer exercise himself by walking in his
+usual manner, but is thrown on the toes and forepart of the feet;
+being, at the same time, irresistibly impelled to take much quicker
+and shorter steps, and thereby to adopt unwillingly a running pace. In
+some cases it is found necessary entirely to substitute running for
+walking; since otherwise the patient, on proceeding only a very few
+paces, would inevitably fall.
+
+In this stage, the sleep becomes much disturbed. The tremulous motion
+of the limbs occur during sleep, and augment until they awaken the
+patient, and frequently with much agitation and alarm. 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 of
+very considerable power: the expulsion of the f�ces from the rectum
+sometimes requiring mechanical aid. As the disease proceeds towards
+its last stage, the trunk is almost permanently bowed, the muscular
+power is more decidedly diminished, and the tremulous agitation
+becomes violent. The patient walks now with great difficulty, and
+unable any longer to support himself with his stick, he dares not
+venture on this 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. His words are now
+scarcely intelligible; and 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, pharynx, &c. impeded by impaired
+action and perpetual agitation, that the food is with difficulty
+retained in the mouth until masticated; and then as difficultly
+swallowed. Now also, from the same cause, another very unpleasant
+circumstance occurs: the saliva fails of being directed to the back
+part of the fauces, and hence is continually draining from the mouth,
+mixed with the particles of food, which he is no longer able to clear
+from the inside of the mouth.
+
+As the debility increases and the influence of the will over the
+muscles fades away, the tremulous agitation becomes more vehement. It
+now seldom leaves him for a moment; but even when exhausted nature
+seizes a small portion of sleep, the motion becomes so violent as not
+only to shake the bed-hangings, but even the floor and sashes of the
+room. The chin is now almost immoveably 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. The urine and f�ces are passed involuntarily; and at the last,
+constant sleepiness, with slight delirium, and other marks of extreme
+exhaustion, announce the wished-for release.
+
+
+                                CASE I.
+
+Almost every circumstance noted in the preceding description, was
+observed in a case which occurred several years back, and which, from
+the particular 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;
+excited an eager wish to acquire some further knowledge of its nature
+and cause.
+
+The subject of this case was a man rather more than fifty years of
+age, who had industriously followed the business of a gardener,
+leading a life of remarkable temperance and sobriety. The commencement
+of the malady was first manifested by a slight trembling of the left
+hand and arm, a circumstance which he was disposed to attribute to his
+having been engaged for several days in a kind of employment requiring
+considerable exertion of that limb. Although repeatedly questioned, he
+could recollect no other circumstance which he could consider as
+having been likely to have occasioned his malady. He had not suffered
+much from Rheumatism, or been subject to pains of the head, or had
+ever experienced any sudden seizure which could be referred to
+apoplexy or hemiplegia. In this case, every circumstance occurred
+which has been mentioned in the preceding history.
+
+
+                               CASE II.
+
+The subject of the case which was next noticed was casually met with
+in the street. It was a man sixty-two years of age; the greater part
+of whose life had been spent as an attendant at a magistrate's office.
+He had suffered from the disease about eight or ten years. All the
+extremities were considerably agitated, the speech was very much
+interrupted, and the body much bowed and shaken. He 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. He described the
+disease as having come on very gradually, and as being, according to
+his full assurance, the consequence of considerable irregularities in
+his mode of living, and particularly of indulgence in spirituous
+liquors. He was the inmate of a poor-house of a distant parish, and
+being fully assured of the incurable nature of his complaint, declined
+making any attempts for relief.
+
+
+                               CASE III.
+
+The next case was also noticed casually in the street. The subject of
+it was a man of about sixty-five years of age, of a remarkable
+athletic frame. The agitation of the limbs, and indeed of the head and
+of the whole body, was too vehement to allow it to be designated as
+trembling. 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. He stated, that he had been a sailor, and
+attributed his complaints to having been for several months confined
+in a Spanish prison, where he had, during the whole period of his
+confinement, lain upon the bare damp earth. The disease had here
+continued so long, and made such a progress, as to afford little or no
+prospect of relief. He besides was a poor mendicant, requiring as well
+as the means of medical experiment, those collateral aids which he
+could only obtain in an hospital. He was therefore recommended to make
+trial if any relief could, in that mode, be yielded him. The poor man,
+however, appeared to be by no means disposed to make the experiment.
+
+
+                               CASE IV.
+
+The next case which presented itself was that of a gentleman about
+fifty-five years, who had first experienced the trembling of the arms
+about five years before. His application was on account of a
+considerable degree of inflammation over the lower ribs on the left
+side, which terminated in the formation of matter beneath the fascia.
+About a pint was removed on making the necessary opening; and a
+considerable quantity discharged daily for two or three weeks. On his
+recovery from this, no change appeared to have taken place in his
+original complaint; and the opportunity of learning its future
+progress was lost by his removal to a distant part of the country.
+
+
+                                CASE V.
+
+In another case, the particulars of which could not be obtained, and
+the gentleman, the lamented subject of which was only seen at a
+distance, one of the characteristic symptoms of this malady, the
+inability for motion, except in a running pace, appeared to exist in
+an extraordinary degree. It seemed to be necessary that the gentleman
+should be supported by his attendant, 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, after his having run about twenty paces.
+
+
+                               CASE VI.
+
+In a case which presented itself to observation since those
+above-mentioned, every information as to the progress of the malady
+was very readily obtained. The gentleman who was the subject of it is
+seventy-two years of age. He has led a life of temperance, and has
+never been exposed to any particular situation or circumstance which
+he can conceive likely to have occasioned, or disposed to this
+complaint; which he rather seems to regard as incidental upon his
+advanced age, than as an object of medical attention. He however
+recollects, that about twenty years ago, he was troubled with
+lumbago, which was severe and lasted some time. About eleven or
+twelve, or perhaps more, years ago, he first perceived weakness in the
+left hand and arm, and soon after found the trembling commence. In
+about three years afterwards the right arm became affected in a
+similar manner: and soon afterwards the convulsive motions affected
+the whole body, and began to interrupt the speech. In about three
+years from that time the legs became affected. Of late years the
+action of the bowels had been very much retarded; and at two or three
+different periods had, with great difficulty, been made to yield to
+the action of very strong cathartics. But within the last twelvemonths
+this difficulty has not been so great; perhaps owing to an increased
+secretion of mucus, which envelopes the passing f�ces, and which
+precedes and follows their discharge in considerable quantity.
+
+About a year since, on waking in the night, he found that he had
+nearly lost the use of the right side, and that the face was much
+drawn to the left side. His medical attendant saw him the following
+day, when he found him languid, with a small and quick pulse, and
+without pain in the head or disposition to sleep. Nothing more
+therefore was done than to promote the action of the bowels, and apply
+a blister to the back of the neck, and in about a fortnight the limbs
+had entirely recovered from their palsied state. During the time of
+their having remained in this state, neither the arm nor the leg of
+the paralytic side was in the least affected with the tremulous
+agitation; but as their paralysed state was removed, the shaking
+returned.
+
+At present he is almost constantly troubled with the agitation, which
+he describes as generally commencing in a slight degree, and gradually
+increasing, until it arises to such a height as to shake the room;
+when, by a sudden and somewhat violent change of posture, he is almost
+always able to stop it. But very soon afterwards it will commence in
+some other limb, in a small degree, and gradually increase in
+violence; but he does not remember the thus checking of it, to have
+been followed by any injurious effect. When the agitation had not
+been thus interrupted, he stated, that it gradually extended through
+all the limbs, and at last affected the whole trunk. To illustrate his
+observation as to the power of suspending the motion by a sudden
+change of posture, 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' time.
+
+He now possessed but little power in giving a required direction to
+the motions of any part. He was scarcely able to feed himself. He had
+written hardly intelligibly for the last three years; and at present
+could not write at all. His attendants observed, that of late the
+trembling would sometimes begin in his sleep, and increase until it
+awakened him: when he always was in a state of agitation and alarm.
+
+On 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.
+
+The preceding 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.
+
+
+
+
+                               CHAP. II.
+
+    PATHOGNOMONIC SYMPTOMS EXAMINED--_TREMOR COACTUS_--_SCELOTYRBE
+                              FESTINANS_.
+
+
+It has been seen in the preceding history of the disease, and in the
+accompanying cases, that certain affections, the tremulous agitations,
+and the almost invincible propensity to run, when wishing only to
+walk, each of which has been considered by nosologists as distinct
+diseases, appear to be pathognomonic symptoms of this malady. To
+determine in which of these points of view these affections ought to
+be regarded, an examination into their nature, and an inquiry into the
+opinions of preceding writers respecting them, seem necessary to be
+attempted.
+
+       *       *       *       *       *
+
+I. _Involuntary tremulous motion, with lessened voluntary muscular
+power, in parts, not in action, and even supported._
+
+It is necessary that the peculiar nature of this tremulous motion
+should be ascertained, as well for the sake of giving to it its
+proper designation, as for assisting in forming probable conjectures,
+as to the nature of the malady, which it helps to characterise.
+Tremors were distinguished by Juncker into Active, those proceeding
+from sudden affection of the minds, as terror, anger, &c. and Passive,
+dependant on debilitating causes, such as advanced age, palsy, &c[2].
+But a much more satisfactory and useful distinction is made by Sylvius
+de la Bo� into those tremors which are produced by attempts at
+voluntary motion, and those which occur whilst the body is at rest[3].
+Sauvages distinguishes the latter of these species (_Tremor Coactus_)
+by observing, that the tremulous parts leap, and as it were vibrate,
+even when supported: whilst every other tremor, he observes, ceases,
+when the voluntary exertion for moving the limb stops, or the part is
+supported, but returns when we will the limb to move; whence, he says,
+tremor is distinguished from every other kind of spasm[4].
+
+    [Footnote 2: Junckeri conspect. de tremore.]
+
+    [Footnote 3: Sect. V. Ubi autem solito pauciores deferunter
+    ad eadem organa spiritus animales, imperfect� ac imbecill�
+    observantur fieri eadem functiones, in motu tremulo et
+    infirmo, nec diu durante, in visu debili, ac mox defatigato,
+    &c.
+
+    Sect. XIX. In�qualiter, inordinat�, ac pr�ter contraque
+    voluntatem moventur spiritus animales per nervos ad partes
+    mobiles, in motu convulsivo, ac tremore, quassuve membrorum
+    coacto.
+
+    Distinguendus namque his tremor quiescente licet ac
+    decumbente corpore molustus a motu tremulo, de quo dictum.
+    Sect. V. Quique quiescente corpore cessat, eodemque iterum
+    moto repetit.
+
+    Sect. XXV. Coactus tremor debetur animalibus spiritibus
+    inordinat� ac continuo, cum aliquo impetu ad trementium
+    membrorum musculos per nervos propulsis: sive fuerit is
+    universalis, sive particularis, sive corpus fuerit ad huc
+    robustum sive debile, Sylvii de la Boe. Prax. lib. i. cap.
+    xlii.]
+
+    [Footnote 4: Nosolog. Methodic. Auctore Fr. Boissier de
+    Sauvages, Tomi. II. Partis ii. p. 54. 1763.]
+
+A small degree of attention will be sufficient to perceive, that
+Sauvages, by this just distinction, actually separates this kind of
+tremulous motion, and which is the kind peculiar to this disease, from
+the Genus Tremor. In doing this he is fully warranted by the
+observations of Galen on the same subject, as noticed by Van
+Swieten[5]. "Binas has tremoris species[6] Galenus subtiliter
+distinxit, atque etiam diversis nominibus insignivit, tremor enim
+([Greek: trom &]) facultatis corpus moventis et vehentis infirmitate
+oboritur. Quippe nemo, qui artus movere non instituerit tremet.
+Palpitantes autem partes, etiam in quiete fuerint, etiamsi nullum
+illis motum induxeris palpitant. Ideo primam (_posteriorem_) modo
+descriptam tremoris speciem, quando quiescenti homini involuntariis
+illis et alternis motibus agitantur membra, palpitationem ([Greek:
+palmon]) dixit, posteriorem (_primam_) vero, qu� non fit nisi homo
+conetur partes quasdam movere tremorem vocavit."
+
+    [Footnote 5: Comment, in Herman. Boerhaav. Aphorismos. Tom.
+    ii. p. 181.]
+
+    [Footnote 6: De tremore. Cap. 3 and 4. Chart, Tom. vii. p.
+    200-201.]
+
+Under this authority the term palpitation may be employed to mark
+those morbid motions which chiefly characterise this disease,
+notwithstanding that this term has been anticipated by Sauvages, as
+characteristic of another species of tremor[7]. The separation of
+palpitation of the limbs (_Palmos_ of Galen, _Tremor Coactus_ of de la
+Bo�) from tremor, is the more necessary to be insisted on, since the
+distinction may assist in leading to a knowledge of the seat of the
+disease. It is also necessary to bear in mind, that this affection is
+distinguishable from tremor, by the agitation, in the former,
+occurring whilst the affected part is supported and unemployed, and
+being even checked by the adoption of voluntary motion; whilst in the
+latter, the tremor is induced immediately on bringing the parts into
+action. Thus an artist, afflicted with the malady here treated of,
+whilst his hand and arm is palpitating strongly, will seize his
+pencil, and the motions will be suspended, allowing him to use it for
+a short period; but in tremor, if the hand be quite free from the
+affection, should the pen or pencil be taken up, the trembling
+immediately commences.
+
+    [Footnote 7: Sect. XVI. _Tremor palpitans_, Preysinger
+    classis morborum. _Palmos_ Galeni.
+
+    In tremoribus vulgaribus, �qualibus temporum intervallis, non
+    musculus, sed artus ipsemet alternatim attollitur aut
+    deprimitur, aut in oppositas partes it atque redit per minima
+    tamen spatiola; in palpitatione ver� sine ullo ordine musculi
+    unius lacertus subito subsilit, nec regulariter continuoque
+    movetur, sed nunc semel aut bis, nunc minim� intra idem
+    tempus subsilit; an causa irritans in sensorio communi, an in
+    musculo ipse palpitante Qu�renda sit, ignoramus. _Nosologi�
+    Methodic�_, Vol. I. p. 559. 1768.
+
+    But the adoption which Sauvages has made of this term, will
+    not be regarded as an absolute prohibition from the
+    employment of it here; since the _tremor palpitans_ of
+    Sauvages should be considered rather as a palpitation of the
+    muscles, whilst the motion which is so prominent a symptom in
+    this disease, may be considered as a palpitation of the
+    limbs.]
+
+       *       *       *       *       *
+
+II. _A propensity to bend the trunk forwards, and to pass from a
+walking to a running pace._
+
+This affection, which observation seems to authorise the being
+considered as a symptom peculiar to this disease, has been mentioned
+by few nosologists: it appears to have been first noticed by Gaubius,
+who says, "Cases occur in which the muscles duly excited into action
+by the impulse of the will, do then, with an unbidden agility, and
+with an impetus not to be repressed, accelerate their motion, and run
+before the unwilling mind. It is a frequent fault of the muscles
+belonging to speech, nor yet of these alone: I have seen one, who was
+able to run, but not to walk[8]."
+
+    [Footnote 8: Est et ubi musculi, recte quidem ad voluntatis
+    nutum in actum concitati, injussa dein agilitate atque impetu
+    non reprimendo motus suos accelerant, mentemque invitam
+    pr�currunt. Vitium loquel� musculis frequens, nec his solis
+    tamen proprium: vidi enim, qui currere, non gradi,
+    poterat[A].]
+
+        [Footnote A: Institution, Patholog. Medicinal. Auctore. H. D.
+        Gaubio. 751.]
+
+Sauvages, referring to this symptom, says, another disease which has
+been very rarely seen by authors, appears to be referable to the same
+genus (Scelotyrbe, of which he makes _Chorea sancti viti_ the first
+species); which, he says, "I think cannot be more fitly named than
+hastening or hurrying Scelotyrbe (_Scelotyrbem festinantem, seu
+festiniam_)."
+
+_Scelotyrbe festinans_, he says, is a peculiar species of scelotyrbe,
+in which the patients, whilst wishing to walk in the ordinary mode,
+are forced to run, which has been seen by Carguet and by the
+illustrious Gaubius; a similar affection of the speech, when the
+tongue thus outruns the mind, is termed volubility. Mons. de Sauvages
+attributes this complaint to a want of flexibility in the muscular
+fibres. Hence, he supposes, that the patients make shorter steps, and
+strive with a more than common exertion or impetus to overcome the
+resistance; walking with a quick and hastened step, as if hurried
+along against their will. _Chorea Viti_, he says, attacks the youth
+of both sexes, but this disease only those advanced in years; and
+adds, that it has hitherto happened to him to have seen only two of
+these cases; and that he has nothing to offer respecting them, either
+in theory or practice[9].
+
+    [Footnote 9: Ad idem genus morbi altera species rarissima ab
+    auctoribus pr�tervisa referenda videtur, quam non aptius
+    nominari posse putem qu�m scelotyrbem festinantem, seu
+    festiniam.
+
+    SECT. II. _Scelotyrbe festinans_: est peculiaris scelotyrbes
+    species in qua �gri solito more dum gradi volunt currere
+    coguntur, quod videre est apud D. Carquet, et observavit
+    Leyd� illustr. Gaubius. _Patholog. instit._ 751, et in
+    loquela h�c _volubilitas_ dicitur qu� lingua pr�currit
+    mentem. Video actu mulierem sexagenariam hoc affectam morbo
+    siccitati nervorum tribuendo; laborat enim rheumatismo sicco,
+    seu ab acrimonia sanguinis, dolores nocte a calore
+    recrudescunt, � thermis non sublevantur: ei pr�scripsi
+    phlebotomiam, et pr�missis jusculis ex lactuc�, endivi�, et
+    collo arietis, lene catharticum, inde vero lacticinia.
+
+    Est affinitas cum scelotyrbe, chorea viti, deest flexibilitas
+    in fibris musculorum; unde motus breves edunt, et conatu seu
+    impetu solito majori, cum resistentiam illam superare
+    nituntur, velut inviti festinant, ac pr�cipiti seu concitato
+    passu gradiuntur. Chorea viti pueros, puellasve impuberes
+    aggreditur; festinia vero senes, et duos tantum hactenus
+    observare mihi contigit. Quam multos autem videmus morbos,
+    paucissimosque observamus. De theoria et pr�xi nihil habeo
+    quod dicam; etenim sola experienta praxin cujusvis morbi
+    determinat, et ex hac pro felici vel infausto successu
+    theoria dein elicienda est. _Nosolog. Methodic._ Auctore, Fr.
+    Boissier de Sauvages. Tomi. II. Part ii. p. 108.]
+
+Having made the necessary inquiries respecting these two affections,
+_Tremor coactum_ of Sylvius de la Bo� and of Sauvages, and _Scelotyrbe
+festinans_ of the latter nosologist, which appear to be characteristic
+symptoms of this disease, it becomes necessary, in the next place, to
+endeavour to distinguish this disease from others which may bear a
+resemblance to it in some particular respects.
+
+
+
+
+                              CHAP. III.
+
+ SHAKING PALSY DISTINGUISHED FROM OTHER DISEASES WITH WHICH IT MAY BE
+                              CONFOUNDED.
+
+
+Treating of a disease resulting from an assemblage of symptoms, some
+of which do not appear to have yet engaged the general notice of the
+profession, particular care is required whilst endeavouring to mark
+its diagnostic characters. It is sufficient, in general, to point out
+the characteristic differences which are observable between diseases
+in some respects resembling each other. But in this case more is
+required: it is necessary to show that it is a disease which does not
+accord with any which are marked in the systematic arrangements of
+nosologists; and that the name by which it is here distinguished has
+been hitherto vaguely applied to diseases very different from each
+other, as well as from that to which it is now appropriated.
+
+Palsy, either consequent to compression of the brain, or dependent on
+partial exhaustion of the energy of that organ, may, when the palsied
+limbs become affected with tremulous motions, be confounded with this
+disease. In those cases the abolition or diminution of voluntary
+muscular action takes place suddenly, the sense of feeling being
+sometimes also impaired. But in this disease, the diminution of the
+influence of the will on the muscles comes on with extreme slowness,
+is always accompanied, and even preceded, by agitations of the
+affected parts, and never by a lessened sense of feeling. The dictates
+of the will are even, in the last stages of the disease, conveyed to
+the muscles; and the muscles act on this impulse, but their actions
+are perverted.
+
+Anomalous cases of convulsive affections have been designated by the
+term Shaking Palsy: a term which appears to be improperly applied to
+these cases, independent of the want of accordance between them and
+that disease which has been here denominated Shaking Palsy. Dr.
+Kirkland, in his commentary on Apoplectic and Paralytic Affections,
+&c. cites the following case, related by Dr. Charlton, as belonging,
+he says, to the class of Shaking Palsies. "Mary Ford, of a sanguineous
+and robust constitution, had an involuntary motion of her right arm,
+occasioned by a fright, which first brought on convulsion fits, and
+most excruciating pain in the stomach, which vanished on a sudden, and
+her right arm was instantaneously flung into an involuntary and
+perpetual motion, like the swing of a pendulum, raising the hand, at
+every vibration higher than her head; but if by any means whatever it
+was stopped; the pain in her stomach came on again, and convulsion
+fits were the certain consequence, which went off when the vibration
+of her hand returned."
+
+Another case, which the Doctor designates as 'A Shaking Palsy,'
+apparently from worms, he describes thus, "A poor boy, about twelve
+or thirteen years of age, was seized with a Shaking Palsy. His legs
+became useless, and together with his head and hands, were in
+continual agitation; after many weeks trial of various remedies, my
+assistance was desired.
+
+"His bowels being cleared, I ordered him a grain of Opium a day in the
+gum pill; and in three or four days the shaking had nearly left him."
+By pursuing this plan, the medicine proving a vermifuge, he could soon
+walk, and was restored to perfect health.
+
+Whether these cases should be classed under Shaking Palsy or not, is
+necessary to be here determined; since, if they are properly ranked,
+the cases which have been described in the preceding pages, differ so
+much from them as certainly to oppose their being classed together:
+and the disease, which is the subject of these pages, cannot be
+considered as the same with Shaking Palsy, as characterised by those
+cases.
+
+The term Shaking Palsy is evidently inapplicable to the first of these
+cases, which appears to have belonged more properly to the genus
+_Convulsio_, of Cullen, or to _Hieranosos_ of Linn�us and Vogel[10].
+
+    [Footnote 10: Corporis agitatio continua, indolens,
+    convulsiva, cum sensibilitate.--_Linn._
+
+    Agitatio corporis vel artuum convulsiva continua, chronica,
+    cum integritate sensuum.--_Vogel._
+
+    This genus is resolved by Cullen into that of Convulsio.
+    _Synops. Nosol._ 1803.
+
+    Dr. Macbride has given a very interesting and illustrative
+    case of this disease.
+
+    "Hieranasos, or Morbus Sacer, so called, as being vulgarly
+    supposed to arise from witchcraft, or some extraordinary
+    celestial influence, is a distinct genus of disease, though a
+    very uncommon one; the author once had an opportunity of
+    seeing a case. The patient was a lad about seventeen, who at
+    that time had laboured under this extraordinary disease for
+    more than twelve years. His body was so distorted, and the
+    legs and arms so twisted round it, by the continued
+    convulsive working, that no words can give an adequate idea
+    of the oddity of his figure; the agitation of the muscles was
+    perpetual; but in general he did not complain of pain nor
+    sickness; and had his senses perfectly, insomuch that he used
+    to assist his mother, who kept a little school, in teaching
+    children to read." _A methodical Introduction to the Theory
+    and Practice of Physic. By David Macbride, M.D. p. 559._]
+
+The latter appears to be referable to that class of proteal forms of
+disease, generated by a disordered state of prim� vi�, sympathetically
+affecting the nervous influence in a distant part of the body.
+
+Unless attention is paid to one circumstance, this disease will be
+confounded with those species of passive tremblings to which the term
+Shaking Palsies has frequently been applied. These are, _tremor
+temulentus_, the trembling consequent to indulgence in the drinking of
+spirituous liquors; that which proceeds from the immoderate employment
+of tea and coffee; that which appears to be dependent on advanced age;
+and all those tremblings which proceed from the various circumstances
+which induce a diminution of power in the nervous system. But by
+attending to that circumstance alone, which has been already noted as
+characteristic of mere tremor, the distinction will readily be made.
+If the trembling limb be supported, and none of its muscles be called
+into action, the trembling will cease. In the real Shaking Palsy the
+reverse of this takes place, the agitation continues in full force
+whilst the limb is at rest and unemployed; and even is sometimes
+diminished by calling the muscles into employment.
+
+
+
+
+                               CHAP. IV.
+
+          PROXIMATE CAUSE--REMOTE CAUSES--ILLUSTRATIVE CASES.
+
+
+Before making the attempt to point out the nature and cause of this
+disease, it is necessary to plead, that it is made under very
+unfavourable circumstances. Unaided by previous inquiries immediately
+directed to this disease, and not having had the advantage, in a
+single case, of that light which anatomical examination yields,
+opinions and not facts can only be offered. Conjecture founded on
+analogy, and an attentive consideration of the peculiar symptoms of
+the disease, have been the only guides that could be obtained for this
+research, the result of which is, as it ought to be, offered with
+hesitation.
+
+                       SUPPOSED PROXIMATE CAUSE.
+
+     A diseased state of the _medulla spinalis_, in that part
+     which is contained in the canal, formed by the superior
+     cervical vertebr�, and extending, as the disease proceeds,
+     to the _medulla oblongata_.
+
+By the nature of the symptoms we are taught, that the disease depends
+on some irregularity in the direction of the nervous influence; by the
+wide range of parts which are affected, that the injury is rather in
+the source of this influence than merely in the nerves of the parts;
+by the situation of the parts whose actions are impaired, and the
+order in which they become affected, that the proximate cause of the
+disease is in the superior part of the medulla spinalis; and by the
+absence of any injury to the senses and to the intellect, that the
+morbid state does not extend to the encephalon.
+
+Uncertainty existing as to the nature of the proximate cause of this
+disease, its remote causes must necessarily be referred to with
+indecision. Assuming however the state just mentioned as the proximate
+cause, it may be concluded that this may be the result of injuries of
+the medulla itself, or of the theca helping to form the canal in which
+it is inclosed.
+
+The great degree of mobility in that portion of the spine which is
+formed by the superior cervical vertebr�, must render it, and the
+contained parts, liable to injury from sudden distortions. Hence
+therefore may proceed inflammation of quicker or of slower progress,
+disease of the vertebr�, derangement of structure in the medulla, or
+in its membranes, thickening or even ulceration of the theca, effusion
+of fluids, &c.
+
+But in no case which has been noticed, has the patient recollected
+receiving any injury of this kind, or any fixed pain in early life in
+these parts, which might have led to the opinion that the foundation
+for this malady had been thus laid. On the subject indeed of remote
+causes, no satisfactory accounts has yet been obtained from any of the
+sufferers. Whilst one has attributed this affliction to indulgence in
+spirituous liquors, and another to long lying on the damp ground; the
+others have been unable to suggest any circumstance whatever, which,
+in their opinion, could be considered as having given origin, or
+disposed, to the calamity under which they suffered.
+
+Cases illustrative of the nature and cause of this malady are very
+rare. In the following case symptoms very similar are observable, so
+far as affecting the lower extremities. That the medulla spinalis was
+here affected, and in its lower part, is not to be doubted: but this,
+unfortunately, was never ascertained by examination. It must be
+however remarked, that this case differed from those which have been
+given of this disease, in the suddenness with which the symptoms
+appeared.
+
+_A. B._ aged twenty-six years, during a course of mercury for a
+venereal affection, was exposed to severely inclement weather, for
+several hours, and the next morning, complained of extreme pain in the
+back, and of total inability to employ voluntarily the muscles of the
+lower extremities, which were continually agitated with severe
+convulsive motions. The physician who attended him employed those
+means which seemed best calculated to relieve him; but with no
+beneficial effect. The lower extremities were perpetually agitated
+with strong palpitatory motions, and, frequently, three or four times
+in a minute, suddenly raised with great vehemence two or three feet
+from the ground, either in a forward or oblique direction, striking
+one limb against the other, or against the chairs, tables, or any
+substance which stood in the way. To check these inordinate motions,
+no means were in the least effectual, except striking the thighs
+forcibly during the more violent convulsions. No advantage was derived
+from all the means which were employed during upwards of twelvemonths.
+Full ten years after this period, the unhappy subject of this malady
+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.
+
+It must be acknowledged, that in the well-known cases, described by
+Mr. Potts, of that kind of Palsy of the lower limbs which is
+frequently found to accompany a curvature of the spine, and in which a
+carious state of the vertebr� is found to exist, no instructive
+analogy is discoverable; slight convulsive motions may indeed happen
+in the disease proceeding from curvature of the spine; but palpitating
+motions of the limbs, such as belong to the disease here described, do
+not appear to have been hitherto noticed.
+
+Whilst striving to determine the nature and origin of this disease, it
+becomes necessary to give the following particulars of an interesting
+case of Palsy occasioned by a fall, attended with uncommon symptoms,
+related by Dr. Maty, in the third volume of the Medical Observations
+and Inquiries. The subject of this case, the Count de Lordat, had the
+misfortune to be overturned from a pretty high and steep bank. His
+head pitched against the top of the coach, and was bent from left to
+right; his left shoulder, arm, and especially his hand, were
+considerably bruised. At first he felt a good deal of pain along the
+left side of his neck, but neither then, nor at any other time, had he
+any faintings, vomitings, or giddiness.--On the sixth day he was let
+blood, on account of the pain in his shoulder and the contusion of his
+hand, which were then the only symptoms he complained of, and of
+which he soon found himself relieved.--Towards the beginning of the
+following winter, he began to find _a small impediment in uttering
+some words, and his left arm appeared weaker_. In the following
+spring, having suffered considerably from the severities of the winter
+campaign, he found _the difficulty in speaking, and in moving his left
+arm, considerably increased_.--On employing the thermal waters of
+Bourbonne, his speech become freer, but, on his return to Paris, the
+Palsy was increased, and the arm somewhat wasted.--In the beginning of
+the next spring he went to Balaruc; when he became affected with
+_involuntary convulsive motions all over the body_. The left arm
+withered more and more, _a spitting began_, and now it was _with
+difficulty that he uttered a few words_. Frictions and sinapisms were
+successively tried, and an issue, made by a caustic, was kept open for
+some time without any effect; but no mention is made of what part the
+issue was established in.
+
+Soon after this, and three years and a half after the fall, Doctor
+Maty first saw the patient, and gives the following description of
+his situation. "A more melancholy object I never beheld. The patient,
+naturally a handsome, middle-sized, sanguine man, of a cheerful
+disposition, and an active mind, appeared much emaciated, stooping,
+and dejected. _He still walked alone with a cane, from one room to the
+other, but with great difficulty, and in a tottering manner_; his left
+hand and arm were much reduced, and would hardly perform any motion;
+_the right was somewhat benumbed, and he could scarcely lift it up to
+his head; his saliva was continually trickling out of his mouth, and
+he had neither the power of retaining it, nor of spitting it out
+freely_. What words he still could utter were monosyllables, and these
+came out, after much struggle, in a violent expiration, and with such
+a low voice and indistinct articulation, as hardly to be understood
+but by those who were constantly with him. He fetched his breath
+rather hard; his pulse was low, but neither accelerated nor
+intermitting. He took very little nourishment, could chew and swallow
+no solids, and even found great pain in getting down liquids. Milk was
+almost his only food; his body was rather loose, his urine natural,
+his sleep good, his senses, and the powers of his mind, unimpaired; he
+was attentive to, and sensible of every thing which was said in
+conversation, and shewed himself very desirous of joining in it; but
+was continually checked by the impediment in his speech, and the
+difficulty which his hearers were put to. Happily for him he was able
+to read, and as capable as ever of writing, as he shewed me, by
+putting into my hands an account of his present situation, drawn up by
+himself: and I am informed that he spent his time to the very last, in
+writing upon some of the most abstruse subjects."
+
+This gentleman died about four years after the accident, when the body
+was examined by Dr. Bellett and Mons. Sorbier, who made the following
+report:
+
+"We first examined the muscles of the tongue, which were found
+extenuated and of a loose texture. We observed no signs of compression
+in the lingual and brachial nerves, as high as their exit from the
+basis of the cranium and the vertebr� of the neck; but they appeared
+to us more compact than they commonly are, being nearly tendinous. The
+dura mater was in a sound state, but the pia mater was full of blood
+and lymph; on it several hydatids, and towards the falx some marks of
+suppuration were observed. The ventricles were filled with water, and
+the plexus choroides was considerably enlarged, and stuffed with
+grumous blood. The cortical surface of the brain appeared much browner
+than usual, but neither the medullary part nor cerebellum were
+impaired. We chiefly took notice of the Medulla Oblongata, this was
+greatly enlarged, surpassing the usual size by more than one third. It
+was likewise more compact. The membranes, which, in their
+continuation, inclose the spinal marrow, were so tough that we found
+great difficulty in cutting through them, and we observed this to be
+the cause of the tendinous texture of the cervical nerves. The marrow
+itself had acquired such solidity as to elude the pressure of our
+fingers, it resisted as a callous body, and could not be bruised. This
+hardness was observed all along the vertebr� of the neck, but lessened
+by degrees, and was not near so considerable in the vertebr� of the
+thorax. Though the patient was but nine and thirty years old, the
+cartilages of the sternum were ossified, and required as much labour
+to cut them asunder as the ribs; like these they were spungy, but
+somewhat whiter. The lungs and heart were sound. At the bottom of the
+stomach appeared an inflammation, which increased as it extended to
+the intestines. The ileum looked of that dark and livid hue, which is
+observed in membranous parts tending to mortification. The colon was
+not above an inch in diameter, the rectum was smaller still, but both
+appeared sound.--From these appearances, we were at no loss to fix the
+cause of this gradual palsy in the alteration of the medulla spinalis
+and oblongata."
+
+Dr. Bellett offers the following explanation of these changes. "I
+conceive, that, by this accident, the head being violently bent to the
+right, the nervous membranes on the left were excessively stretched
+and irritated; that this cause extended by degrees to the spinal
+marrow, which being thereby compressed, brought on the paralytic
+symptoms, not only of the left arm, but at last in some measure also
+of the right. This induration seems to have been occasioned by the
+constant afflux of the nutritive juices, which were stopt at that
+place, and deprived of their most liquid parts; the grosser ones being
+unable to spread in the boney cavity, by which they were confined,
+could only acquire a greater solidity, and change a soft body into a
+hard and nearly osseous mass. This likewise accounts for the increase
+of the medulla oblongata, which being loaded with more juices than it
+could send off, swelled in the same manner as the branches of trees,
+which will grow of a monstrous size, when the sap that runs into them
+is stopt in its progress. The medulla oblongata not growing so hard as
+the spinalis, was doubtless owing to its not being confined in an
+osseous theca, but surrounded with soft parts, which allowed it room
+to spread. The obstruction from the bulk of this substance must have
+affected the brain, and probably induced the thickening of the pia
+mater, the hydatids, and the beginning of suppuration, whereas the
+dura mater, being of a harder texture, was not injured[11]."
+
+    [Footnote 11: Medical Observations and Inquiries, Vol. III.
+    p. 257.]
+
+In some of the symptoms which appeared in this case, an agreement is
+observable between it and those cases which are mentioned in the
+beginning of these pages. The weakened state of both arms; the power
+first lessening in one arm, and then in a similar manner in the other
+arm; the affection of the speech; the difficulty in chewing and in
+swallowing; as well as of retaining, or freely discharging, the
+spittle; the convulsive motions of the body; and the unimpaired state
+of the intellects; constitute such a degree of accordance as, although
+it may not mark an identity of disease, serves at least to show that
+nearly the same parts were the seat of the disease in both instances.
+Thus we attain something like confirmation of the supposed proximate
+cause, and of one of the assumed occasional causes.
+
+Whilst conjecturing as to the cause of this disease, the following
+collected observations on the effects of injury to the medulla
+spinalis, by Sir Everard Home, become particularly deserving of
+attention. It thence appears, that none of the characteristic symptoms
+of this malady are produced by compression, laceration, or complete
+division of the medulla spinalis.
+
+"Pressure upon the medulla spinalis of the neck, by coagulated blood,
+produced paralytic affections of the arms and legs; all the functions
+of the internal organs were carried on for thirty-five days, but the
+urine and stools passed involuntarily[12].
+
+    [Footnote 12: A coagulum of blood, the thickness of a
+    crown-piece, was found lying upon the external surface of the
+    dura-matral covering of the medulla spinalis, extending from
+    the fourth vertebra colli to the second vertebra dorsi. The
+    medulla spinalis itself was uninjured.]
+
+"Blood extravasated in the central part of the medulla, in the neck,
+was attended with paralytic affection of the legs, but not of the
+arms[13].
+
+    [Footnote 13: The sixth and seventh vertebra colli were
+    dislocated, the medulla spinalis, externally, was uninjured;
+    but in the centre of its substance, just at that part, there
+    was a coagulum of blood nearly two inches in length.]
+
+"In a case where the substance of the medulla was lacerated in the
+neck, there was a paralysis in all the parts below the laceration, the
+lining of the oesophagus was so sensible, that solids could not be
+swallowed, on account of the pain they occasioned[14].
+
+    [Footnote 14: The seventh vertebra colli was fractured, and
+    the medulla spinalis passing through it, was lacerated and
+    compressed.]
+
+"When the medulla of the back was completely divided, there was
+momentary loss of sight, loss of memory for fifteen minutes, and
+permanent insensibility in all the lower parts of the body. The skin
+above the division of the spinal marrow perspired, that below did not.
+The wounded spinal marrow appeared to be extremely sensible[15]."
+_Philosophical Transactions_, 1816, p. 485.
+
+    [Footnote 15: The spinal marrow, within the canal of the
+    sixth vertebra dorsi, was completely destroyed by a musket
+    ball. The person lived four days.]
+
+In two of the cases already noticed, symptoms of rheumatism had
+previously existed; and in Case IV. the right arm, in which the
+palpitation began, was said to have been very violently affected with
+rheumatic pain to the fingers ends. The consideration of this case, in
+which the palpitation had been preceded, at a considerable distance of
+time, by this painful affection of the arm, led to the supposition
+that this latter circumstance might be the cause of the palpitations,
+and the other subsequent symptoms of this disease. This supposition
+naturally occasioned the attention to be eagerly fixed on the
+following case; and of course influenced the mode of treatment which
+was adopted.
+
+_A. B._ subject to rheumatic affection of the deltoid muscle, had felt
+the usual inconveniences from it for two or three days; but at night
+found the pain had extended down the arm, along the inside of the
+fore-arm, and on the sides of the fingers, in which a continual
+tingling was felt. The pain, without being extremely intense, was such
+as effectually to prevent sleep: and seemed to follow the course of
+the brachial nerve. Whilst ascertaining the propriety of this
+conclusion, the pain was found to ramify, as it were, on the fore and
+back part of the chest; and was slightly augmented by drawing a deep
+breath.
+
+These circumstances suggested the probability of slight inflammation,
+or increased determination to the origin of the nerves of these parts,
+and to the neighbouring medulla. On this ground, blood was taken from
+the back part of the neck, by cupping; hot fomentations were applied
+for about the space of an hour, when the upper part of the back of the
+neck was covered with a blister, perspiration was freely induced by
+two or three small doses of antimonials, and the following morning the
+bowels were evacuated by an appropriate dose of calomel. On the
+following day the pains were much diminished, and in the course of
+four or five days were quite removed. The arm and hand felt now more
+than ordinarily heavy, and were evidently much weakened: aching, and
+feeling extremely wearied after the least exertion. The strength of
+the arm was not completely recovered at the end of more than
+twelvemonths; and, after more than twice that time, exertion would
+excite the feeling of painful weariness, but no palpitation or other
+unpleasant symptom has occurred during the five or six years which
+have since passed.
+
+The commencement, progress, and termination of this attack; with the
+success attending the mode of treatment, and the symptoms which
+followed, seem to lead to the conjecture, that the proximate cause of
+the disease, in this case, existed in the medulla spinalis, and that
+it might, if neglected, have gradually resolved itself into that
+disease which is the object of our present inquiry.
+
+Some few months after the occurrence of the preceding case, the writer
+of these lines was called to a female about forty years of age,
+complaining of great pain in both the arms, extending from the
+shoulder to the finger ends. She stated, that she was attacked in the
+same manner as is described in the preceding case, about nine months
+before; that the complaint was considered as rheumatism, and was not
+benefited by any of the medicines which had been employed; but that
+after three or four weeks it gradually amended, leaving both the arms
+and hands in a very weakened and trembling state. From this state they
+were now somewhat recovered; but she was extremely anxious, fearing
+that if the present attack should not be soon checked, she might
+entirely lose the use of her hands and arms.
+
+Instructed by the preceding case, similar means were here recommended.
+Leeches, stimulating fomentations, and a blister, which was made for
+sometime to yield a purulent discharge, were applied over the cervical
+vertebr�; and in the course of a very few days the pain was entirely
+removed. It is regretted that no farther information, as to the
+progress of this case, could be obtained.
+
+On meeting with these two cases, it was thought that it might not be
+improbable that attacks of this kind, considered at the time merely as
+rheumatic affections, might lay the foundation of this lamentable
+disease, which might manifest itself at some distant period, when the
+circumstance in which it had originated, had, perhaps, almost escaped
+the memory. Indeed when it is considered that neither in the ordinary
+cases of Palsy of the lower extremities, proceeding from diseased
+spine, nor in cases of injured medulla from fractured vertebr�, any of
+the peculiar symptoms of this disease are observable, we necessarily
+doubt as to the probability of its being the direct effect of any
+sudden injury. But taking all circumstances into due consideration,
+particularly the very gradual manner in which the disease commences,
+and proceeds in its attacks; as well as the inability to ascribe its
+origin to any more obvious cause, we are led to seek for it in some
+slow morbid change in the structure of the medulla, or its investing
+membranes, or theca, occasioned by simple inflammation, or rheumatic
+or scrophulous affection.
+
+It must be too obvious that the evidence adduced as to the nature of
+the proximate and occasional causes of this disease, is by no means
+conclusive. A reference to the test therefore which will be yielded by
+an examination of some of the more prominent symptoms, especially as
+to their agreement with the supposed proximate cause, is more
+particularly demanded. Satisfied as to the importance of this part of
+the present undertaking, no apology is offered for the extent to which
+the examination is carried on.
+
+If the palpitation and the attendant weakness of the limbs, &c. be
+considered as to the order in which the several parts are attacked, it
+is believed, that some confirmation will be obtained of the opinion
+which has been just offered, respecting the cause, or at least the
+seat, of that change which may be considered as the proximate cause of
+this disease.
+
+One of the arms, in all the cases which have been here mentioned, has
+been the part in which these symptoms have been first noticed; the
+legs, head, and trunk have then become gradually affected, and lastly,
+the muscles of the mouth and fauces have yielded to the morbid
+influence.
+
+The arms, the parts first manifesting disordered action, of course
+direct us, whilst searching for the cause of these changes, to the
+brachial nerves. But finding the mischief extending to other parts,
+not supplied with these, but with other nerves derived from nearly the
+same part of the medulla spinalis, we are of course led to consider
+that portion of the medulla spinalis itself, from which these nerves
+are derived, as the part in which those changes have taken place,
+which constitute the proximate cause of this disease.
+
+From the subsequent affection of the lower extremities, and from the
+failure of power in the muscles of the trunk, such a change in the
+substance of the medulla spinalis may be inferred, as shall have
+considerably interrupted, and interfered with, the extension of the
+nervous influence to those parts, whose nerves are derived from any
+portion of the medulla below the part which has undergone the diseased
+change.
+
+The difficulty in supporting the trunk erect, as well as the
+propensity to the adopting of a hurried pace, is also referable to
+such a diminution of the nervous power in the extensor muscles of the
+head and trunk, as prevents them from performing the offices of
+maintaining the head and body in an erect position.
+
+From the impediment to speech, the difficulty in mastication and
+swallowing, the inability to retain, or freely to eject, the Saliva,
+may with propriety be inferred an extension of the morbid change
+upwards through the medulla spinalis to the medulla oblongata,
+necessarily impairing the powers of the several nerves derived from
+that portion into which the morbid change may have reached. In the
+late occurrence of this set of symptoms, and the extension upwards of
+the diseased state, a very close agreement is observable between this
+disease and that which has been already shown, proved fatal to the
+Count de Lordat. But in this case, the disease doubtlessly became
+differently modified, and its symptoms considerably accelerated, in
+consequence of the magnitude of the injury by which the disease was
+induced.
+
+
+
+
+                               CHAP. V.
+
+             CONSIDERATIONS RESPECTING THE MEANS OF CURE.
+
+
+The inquiries made in the preceding pages yield, it is to be much
+regretted, but little more than evidence of inference: nothing direct
+and satisfactory has been obtained. All that has been ventured to
+assume here, has been that the disease depends on a disordered state
+of that part of the medulla which is contained in the cervical
+vertebr�. But of what nature that morbid change is; and whether
+originating in the medulla itself, in its membranes, or in the
+containing theca, is, at present, the subject of doubt and conjecture.
+But although, at present, uninformed as to the precise nature of the
+disease, still it ought not to be considered as one against which
+there exists no countervailing remedy.
+
+On the contrary, there appears to be sufficient reason for hoping that
+some remedial process may ere long be discovered, by which, at least,
+the progress of the disease may be stopped. It seldom happens that
+the agitation extends beyond the arms within the first two years;
+which period, therefore, if we were disposed to divide the disease
+into stages, might be said to comprise the first stage. In this
+period, it is very probable, that remedial means might be employed
+with success: and even, if unfortunately deferred to a later period,
+they might then arrest the farther progress of the disease, although
+the removing of the effects already produced, might be hardly to be
+expected.
+
+From a review of the changes which had taken place in the case of
+Count de Lordat, it seems as if we were able to trace the order and
+mode in which the morbid changes may proceed in this disease. From any
+occasional cause, the thecal ligament, the membranes, or the medulla
+itself, may pass into the state of simple excitement or irritation,
+which may be gradually succeeded by such a local afflux and
+determination of blood into the minute vessels, as may terminate in
+actual but slow inflammation. The result of this would be a
+thickening of the theca, or membranes, and perhaps an increase in the
+volume of the medulla itself, which would gradually occasion such a
+degree of pressure against the sides of the unyielding canal, as must
+eventually intercept the influence of the brain upon the inferior
+portion of the medullary column, and upon the parts on which the
+nerves of this portion are disposed.
+
+From this review, and assuming that the morbid changes in this disease
+may not be widely dissimilar from those which occurred in the case of
+Count de Lordat, the chance of relief from the proposed mode of
+treatment may appear to be sufficient to warrant its trial.
+
+In such a case then, at whatever period of the disease it might be
+proposed to attempt the cure, blood should be first taken from the
+upper part of the neck, unless contra-i(n)dicated by any particul(ar)
+circumstance. After which vesicatories should be applied to the (sa)me
+part, and a purulent discharge obtained by appropriate use of the
+Sabine Liniment; having recourse to the application of a fresh
+blister, when from the diminution of the discharging surface, pus is
+not secreted in a sufficient quantity. Should the blisters be found
+too inconvenient, or a sufficient quantity of discharge not be
+obtained thereby, an issue of at least an inch and a half in length
+might be established on each side of the vertebral columna, in its
+superior part. These, it is presumed, would be best formed with
+caustic, and kept open with any proper substance[16].
+
+    [Footnote 16: Cork, which has been hitherto neglected,
+    appears to be very appropriate to this purpose. It possesses
+    lightness, softness, elasticity and sufficient firmness; and
+    is also capable of being readily fashioned to any convenient
+    form. The form which it seems would be best adapted to the
+    part, is that of an almond, or of the variety of bean called
+    scarlet bean; but at least an inch and a half in length.]
+
+Could it have been imagined that such considerable benefit: indeed,
+that such astonishing cures, could have been effected by issues in
+cases of Palsy of the lower extremities from diseased spine? although
+satisfied with ascribing those cases to scrofulous action, we are in
+fact as little informed respecting the nature of the affection,
+inducing the carious state of the vertebr�, as we are respecting the
+peculiar change of structure which takes place in this disease.
+Equally uninformed are we also as to the peculiar kind of morbid
+action, which takes place in the ligaments of the joints; as well as
+that which takes place in different instances of deep seated pains and
+affections of the parts contained in the head, thorax, and abdomen,
+and in all which cases the inducing of a purulent discharge in their
+neighbourhood is so frequently productive of a cure. Experiment has
+not indeed been yet employed to prove, but analogy certainly warrants
+the hope, that similar advantages might be derived from the use of the
+means enumerated, in the present disease. It is obvious, that the
+chance of obtaining relief will depend in a great measure on the
+period at which the means are employed. As in every other disease, so
+here, the earlier the remedies are resorted to, the greater will be
+the probability of success. But in this disease there is one
+circumstance which demands particular attention; the long period to
+which it may be extended. One of its peculiar symptoms, Scelotyrbe
+festinans, may not occur until the disease has existed ten or twelve
+years, or more; hence, when looking for the period, within which our
+hopes of remedial aid is to be limited; we may, guided by the slow
+progress of the malady, extend it to a great length, when compared
+with that within which we should be obliged to confine ourselves in
+most other diseases.
+
+But it is much to be apprehended, as in many other cases, that the
+resolution of the patients will seldom be sufficient to enable them to
+persevere through the length of time which the proposed process will
+necessarily require. As slow as is the progress of the disease, so
+slow in all probability must be the period of the return to health. In
+most cases, especially in those in which the disease has been allowed
+to exist long unopposed, it may be found that all that art is capable
+of accomplishing, is that of checking its further progress. Nor will
+this be regarded as a trifle, when, by reference to the history of the
+disease, is seen the train of harassing evils which would be thus
+avoided.
+
+But it seems as if there existed reason for hoping for more. For
+supposing change of structure to have taken place, it is extremely
+probable that this change may be merely increase in mass or volume by
+interstitial addition, the consequence of increased action in the
+minute vessels of the part. In that case, should the instituting of a
+purulent discharge, in a neighbouring part, act in the manner which we
+would presume it may--should it by keeping up a constant discharge,
+not merely alter the determination, but diminish the inordinate action
+of the vessels in the diseased part; and at the same time excite the
+absorbents to such increased action as may remove the added matter;
+there will exist strong ground for hope, that a happy, though slow
+restoration to health, may be obtained.
+
+Until we are better informed respecting the nature of this disease,
+the employment of internal medicines is scarcely warrantable; unless
+analogy should point out some remedy the trial of which rational hope
+might authorize. Particular circumstances indeed must arise in
+different cases, in which the aid of medicine may be demanded: and the
+intelligent will never fail to avail themselves of any opportunity of
+making trial of the influence of mercury, which has in so many
+instances, manifested its power in correcting derangement of
+structure.
+
+The weakened powers of the muscles in the affected parts is so
+prominent a symptom, as to be very liable to mislead the inattentive,
+who may regard the disease as a mere consequence of constitutional
+debility. If this notion be pursued, and tonic medicines, and highly
+nutritious diet be directed, no benefit is likely to be thus obtained;
+since the disease depends not on general weakness, but merely on the
+interruption of the flow of the nervous influence to the affected
+parts.
+
+It is indeed much to be regretted that this malady is generally
+regarded by the sufferers in this point of view, so discouraging to
+the employment of remedial means. Seldom occurring before the age of
+fifty, and frequently yielding but little inconvenience for several
+months, it is generally considered as the irremediable diminution of
+the nervous influence, naturally resulting from declining life; and
+remedies therefore are seldom sought for.
+
+Although unable to trace the connection by which a disordered state of
+the stomach and bowels may induce a morbid action in a part of the
+medulla spinalis, yet taught by the instruction of Mr. Abernethy,
+little hesitation need be employed before we determine on the
+probability of such occurrence. The power, possessed by sympathy, of
+inducing such disordered action in a distant part, and the probability
+of such disordered action producing derangement of structure, can
+hardly be denied. The following Case seems to prove, at least, that
+the mysterious sympathetic influence which so closely simulates the
+forms of other diseases, may induce such symptoms as would seem to
+menace the formation of a disease not unlike to that which we have
+been here treating of.
+
+_A. B._ A man, 54 years of age, of temperate habits and regular state
+of bowels, became gradually affected with slight numbness and
+prickling, with a feeling of weakness in both arms, accompanied by a
+sense of fulness about the shoulders, as if produced by the pressure
+of a strong ligature; and at times a slight trembling of the hands.
+During the night, the fullness, numbness, and prickling were much
+increased. The appetite had been diminished for several weeks; and the
+abdomen, on being examined, felt as though containing considerable
+accumulation.
+
+Before adopting any other measures, and as there appeared to be no
+marks of vascular fulness, it was determined to empty the bowels. This
+was done effectually by moderate doses of calomel, with the occasional
+help of Epsom salts; and in about ten days, by these means alone, the
+complaints were entirely removed.
+
+Before concluding these pages, it may be proper to observe once more,
+that an important object proposed to be obtained by them is, the
+leading of the attention of those who humanely employ anatomical
+examination in detecting the causes and nature of diseases,
+particularly to this malady. By their benevolent labours its real
+nature may be ascertained, and appropriate modes of relief, or even of
+cure, pointed out.
+
+To such researches the healing art is already much indebted for the
+enlargement of its powers of lessening the evils of suffering
+humanity. Little is the public aware of the obligations it owes to
+those who, led by professional ardour, and the dictates of duty, have
+devoted themselves to these pursuits, under circumstances most
+unpleasant and forbidding. Every person of consideration and feeling,
+may judge of the advantages yielded by the philanthropic exertions of
+a HOWARD; but how few can estimate the benefits bestowed on mankind,
+by the labours of a MORGAGNI, HUNTER, or BAILLIE.
+
+
+                                FINIS.
+
+
+
+
+
+End of Project Gutenberg's An Essay on the Shaking Palsy, by James Parkinson
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+      The Project Gutenberg eBook of An Essay on the Shaking Palsy, by James Parkinson
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+<pre>
+
+Project Gutenberg's An Essay on the Shaking Palsy, by James Parkinson
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+
+Title: An Essay on the Shaking Palsy
+
+Author: James Parkinson
+
+Release Date: December 9, 2007 [EBook #23777]
+
+Language: English
+
+Character set encoding: ISO-8859-1
+
+*** START OF THIS PROJECT GUTENBERG EBOOK AN ESSAY ON THE SHAKING PALSY ***
+
+
+
+
+Produced by Irma Spehar and the Online Distributed
+Proofreading Team at http://www.pgdp.net
+
+
+
+
+
+
+</pre>
+
+
+
+
+<h1><span style="font-size: 60%">AN</span><br /><br />
+<span style="letter-spacing: 0.20ex">ESSAY</span><br /><br />
+<span style="font-size: 50%">ON THE</span><br /><br />
+<span style="letter-spacing: 0.20ex">SHAKING PALSY.</span></h1>
+
+<hr class="title" style="margin-top: 4em; width: 10%" />
+
+<p class="center" style="padding-top: 2em; font-size: 90%">BY</p>
+
+<p class="center" style="font-size: 120%; font-weight: bold"><i>JAMES PARKINSON</i>,<br />
+
+<span style="font-size: 60%; font-weight: normal">MEMBER OF THE ROYAL COLLEGE OF SURGEONS.</span></p>
+
+<hr class="title" style="margin-top: 3em" />
+
+<p class="publisher"><i>LONDON</i>:<br />
+
+<span style="font-size: 70%">PRINTED BY WHITTINGHAM AND ROWLAND,</span><br />
+
+<span style="font-size: 70%"><i>Goswell Street</i>,</span><br /><br />
+
+<span style="letter-spacing: 0.20ex">FOR SHERWOOD, NEELY, AND JONES,</span><br />
+
+<span style="font-size: 70%">PATERNOSTER ROW.</span><br /><br />
+
+1817.</p>
+
+
+
+<h2><a name="PREFACE" id="PREFACE"></a>PREFACE.</h2>
+
+
+<p><span class="smcap">The</span> advantages which have been derived
+from the caution with which hypothetical
+statements are admitted, are in no instance
+more obvious than in those sciences which
+more particularly belong to the healing art.
+It therefore is necessary, that some conciliatory
+explanation should be offered for
+the present publication: in which, it is
+acknowledged, that mere conjecture takes
+the place of experiment; and, that analogy
+is the substitute for anatomical examination,
+the only sure foundation for
+pathological knowledge.</p>
+
+<p>When, however, the nature of the subject,
+and the circumstances under which it has
+been here taken up, are considered, it is<span class='pagenum'><a name="Page_ii" id="Page_ii">[ii]</a></span>
+hoped that the offering of the following pages
+to the attention of the medical public, will
+not be severely censured. The disease, respecting
+which the present inquiry is made,
+is of a nature highly afflictive. Notwithstanding
+which, it has not yet obtained a
+place in the classification of nosologists;
+some have regarded its characteristic symptoms
+as distinct and different diseases, and
+others have given its name to diseases differing
+essentially from it; whilst the unhappy
+sufferer has considered it as an evil, from the
+domination of which he had no prospect of
+escape.</p>
+
+<p>The disease is of long duration: 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. Of both these advantages
+the writer has had the opportunities of availing<span class='pagenum'><a name="Page_iii" id="Page_iii">[iii]</a></span>
+himself; and has hence been led particularly
+to observe several other cases in
+which the disease existed in different stages
+of its progress. By these repeated observations,
+he hoped that he had been led to a
+probable conjecture as to the nature of the
+malady, and that analogy had suggested such
+means as might be productive of relief, and
+perhaps even of cure, if employed before
+the disease had been too long established.
+He therefore considered it to be a duty to
+submit his opinions to the examination of
+others, even in their present state of immaturity
+and imperfection.</p>
+
+<p>To delay their publication did not, indeed,
+appear to be warrantable. The disease had
+escaped particular notice; and the task of
+ascertaining its nature and cause by anatomical
+investigation, did not seem likely to be
+taken up by those who, from their abilities
+and opportunities, were most likely to accomplish
+it. That these friends to humanity<span class='pagenum'><a name="Page_iv" id="Page_iv">[iv]</a></span>
+and medical science, who have already
+unveiled to us many of the morbid processes
+by which health and life is abridged, might
+be excited to extend their researches to this
+malady, was much desired; and it was hoped,
+that this might be procured by the publication
+of these remarks.</p>
+
+<p>Should the necessary information be thus
+obtained, the writer will repine at no censure
+which the precipitate publication of
+mere conjectural suggestions may incur;
+but shall think himself fully rewarded by
+having excited the attention of those, who
+may point out the most appropriate means
+of relieving a tedious and most distressing
+malady.</p>
+
+
+
+<h2><a name="CONTENTS" id="CONTENTS"></a>CONTENTS.</h2>
+
+
+<table>
+<tr><td>&nbsp;</td><td class="pageno"><span style="font-size: 50%">PAGE</span></td></tr>
+<tr><td colspan="2" class="chapter"><span class="smcap">Chap.</span> I.</td></tr>
+<tr><td><span class="smcap">Definition&mdash;history&mdash;illustrative cases</span></td><td class="pageno"><a href="#Page_1">1</a></td></tr>
+<tr><td colspan="2" class="chapter"><span class="smcap">Chap.</span> II.</td></tr>
+<tr><td><span class="smcap">Pathognomonic symptoms examined&mdash;tremor
+coactus&mdash;scelotyrbe festinans</span></td><td class="pageno"><a href="#Page_19">19</a></td></tr>
+<tr><td colspan="2" class="chapter"><span class="smcap">Chap.</span> III.</td></tr>
+<tr><td><span class="smcap">Shaking palsy distinguished from other diseases
+with which it may be confounded</span></td><td class="pageno"><a href="#Page_27">27</a></td></tr>
+<tr><td colspan="2" class="chapter"><span class="smcap">Chap.</span> IV.</td></tr>
+<tr><td><span class="smcap">Proximate cause&mdash;remote causes&mdash;illustrative
+cases</span></td><td class="pageno"><a href="#Page_33">33</a></td></tr>
+<tr><td colspan="2" class="chapter"><span class="smcap">Chap.</span> V.</td></tr>
+<tr><td><span class="smcap">Considerations respecting the means of cure</span></td><td class="pageno"><a href="#Page_56">56</a></td></tr>
+</table>
+
+
+
+<h1 style="padding-top: 2em; padding-bottom: 1em"><span style="font-size: 50%">AN</span><br />
+<span style="letter-spacing: 0.20ex">ESSAY</span><br />
+<span style="font-size: 50%">ON THE</span><br />
+<span style="letter-spacing: 0.20ex">SHAKING PALSY.</span></h1>
+
+
+<h2 style="padding-bottom: 0em"><a name="CHAPTER_I" id="CHAPTER_I"></a>CHAPTER I.<span class='pagenum'><a name="Page_1" id="Page_1">[1]</a></span></h2>
+
+<h3>DEFINITION&mdash;HISTORY&mdash;ILLUSTRATIVE CASES.</h3>
+
+
+<h4>SHAKING PALSY. (<i>Paralysis Agitans.</i>)</h4>
+
+<div class="blockquot"><p>Involuntary tremulous motion, with lessened
+muscular 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.</p></div>
+
+<p><span class="smcap">The</span> term Shaking Palsy has been vaguely
+employed by medical writers in general.
+By some it has been used to designate ordinary<span class='pagenum'><a name="Page_2" id="Page_2">[2]</a></span>
+cases of Palsy, in which some slight
+tremblings have occurred; whilst by others
+it has been applied to certain anomalous affections,
+not belonging to Palsy.</p>
+
+<p>The shaking of the limbs belonging to this
+disease was particularly noticed, as will be
+seen when treating of the symptoms, by
+Galen, who marked its peculiar character
+by an appropriate term. The same symptom,
+it will also be seen, was accurately
+treated of by Sylvius de la Bo&euml;. Juncker
+also seems to have referred to this symptom:
+having divided tremor into active and
+passive, he says of the latter, &#8220;ad affectus
+semiparalyticos pertinent; de qualibus hic
+agimus, quique <i>tremores paralytoidei</i> vocantur.&#8221;
+Tremor has been adopted, as a genus,
+by almost every nosologist; but always unmarked,
+in their several definitions, by such
+characters as would embrace this disease.
+The celebrated Cullen, with his accustomed
+accuracy observes, &#8220;Tremorem, utpote semper
+symptomaticum, in numerum generum
+recipere nollem; species autem a Sauvagesio
+recensitas, prout mihi vel astheni&aelig; vel paralysios,
+vel convulsionis symptomata esse<span class='pagenum'><a name="Page_3" id="Page_3">[3]</a></span>
+videntur, his subjungam<a name="FNanchor_1_1" id="FNanchor_1_1"></a><a href="#Footnote_1_1" class="fnanchor">[1]</a>.&#8221; Tremor can indeed
+only be considered as a symptom, although
+several species of it must be admitted.
+In the present instance, the agitation
+produced by the peculiar species of tremor,
+which here occurs, is chosen to furnish the
+epithet by which this species of Palsy, may
+be distinguished.</p>
+
+
+<h4>HISTORY.</h4>
+
+<p>So slight and nearly imperceptible are
+the first inroads of this malady, and so extremely
+slow is its progress, that it rarely
+happens, that the patient can form any recollection
+of the precise period of its commencement.
+The first symptoms perceived
+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. These
+symptoms gradually increase in the part
+first affected; and at an uncertain period,
+but seldom in less than twelvemonths or
+more, the morbid influence is felt in some
+other part. Thus assuming one of the
+<span class='pagenum'><a name="Page_4" id="Page_4">[4]</a></span>hands and arms to be first attacked, the other,
+at this period becomes similarly affected.
+After a few more months the patient is
+found to be less strict than usual in preserving
+an upright posture: this being most
+observable whilst walking, but sometimes
+whilst sitting or standing. Sometime after
+the appearance of this symptom, and during
+its slow increase, one of the legs is discovered
+slightly to tremble, and is also found
+to suffer fatigue sooner than the leg of the
+other side: and in a few months this limb
+becomes agitated by similar tremblings,
+and suffers a similar loss of power.</p>
+
+<p>Hitherto the patient will have experienced
+but little inconvenience; and befriended
+by the strong influence of habitual
+endurance, would perhaps seldom think of
+his being the subject of disease, except
+when reminded of it by the unsteadiness of
+his hand, whilst writing or employing himself
+in any nicer kind of manipulation.
+But as the disease proceeds, similar employments
+are accomplished with considerable
+difficulty, the hand failing to answer with
+exactness to the dictates of the will. Walking<span class='pagenum'><a name="Page_5" id="Page_5">[5]</a></span>
+becomes a task which cannot be performed
+without considerable attention. The legs are
+not raised to that height, or with that promptitude
+which the will directs, so that the utmost
+care is necessary to prevent frequent
+falls.</p>
+
+<p>At this period the patient experiences
+much inconvenience, which unhappily is
+found daily to increase. The submission of
+the limbs to the directions of the will can
+hardly ever be obtained in the performance
+of the most ordinary offices of life. The
+fingers cannot be disposed of in the proposed
+directions, and applied with certainty to
+any proposed point. As time and the disease
+proceed, difficulties increase: writing can
+now be hardly at all accomplished; and
+reading, from the tremulous motion, is accomplished
+with some difficulty. Whilst
+at meals the fork not being duly directed
+frequently fails to raise the morsel from the
+plate: which, when seized, is with much
+difficulty conveyed to the mouth. At this
+period the patient seldom experiences a
+suspension of the agitation of his limbs.
+Commencing, for instance in one arm, the<span class='pagenum'><a name="Page_6" id="Page_6">[6]</a></span>
+wearisome agitation is borne until beyond
+sufferance, when by suddenly changing the
+posture it is for a time stopped in that limb,
+to commence, generally, in less than a
+minute in one of the legs, or in the arm of
+the other side. Harassed by this tormenting
+round, the patient has recourse to
+walking, a mode of exercise to which the
+sufferers from this malady are in general
+partial; owing to their attention being
+thereby somewhat diverted from their unpleasant
+feelings, by the care and exertion
+required to ensure its safe performance.</p>
+
+<p>But as the malady proceeds, even this
+temporary mitigation of suffering from the
+agitation of the limbs is denied. 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, when this state
+of the malady is attained, the patient can
+no longer exercise himself by walking in his
+usual manner, but is thrown on the toes
+and forepart of the feet; being, at the same<span class='pagenum'><a name="Page_7" id="Page_7">[7]</a></span>
+time, irresistibly impelled to take much
+quicker and shorter steps, and thereby to
+adopt unwillingly a running pace. In
+some cases it is found necessary entirely to
+substitute running for walking; since otherwise
+the patient, on proceeding only a very
+few paces, would inevitably fall.</p>
+
+<p>In this stage, the sleep becomes much
+disturbed. The tremulous motion of the
+limbs occur during sleep, and augment
+until they awaken the patient, and frequently
+with much agitation and alarm.
+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 of very considerable power: the
+expulsion of the f&aelig;ces from the rectum sometimes
+requiring mechanical aid. As the disease
+proceeds towards its last stage, the trunk
+is almost permanently bowed, the muscular
+power is more decidedly diminished, and
+the tremulous agitation becomes violent.
+The patient walks now with great difficulty,
+and unable any longer to support himself<span class='pagenum'><a name="Page_8" id="Page_8">[8]</a></span>
+with his stick, he dares not venture on this
+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.
+His words are now scarcely intelligible;
+and 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, pharynx, &amp;c. impeded
+by impaired action and perpetual agitation,
+that the food is with difficulty retained
+in the mouth until masticated; and then as
+difficultly swallowed. Now also, from the
+same cause, another very unpleasant circumstance
+occurs: the saliva fails of being
+directed to the back part of the fauces, and
+hence is continually draining from the
+mouth, mixed with the particles of food,
+which he is no longer able to clear from the
+inside of the mouth.</p>
+
+<p>As the debility increases and the influence
+of the will over the muscles fades
+away, the tremulous agitation becomes
+more vehement. It now seldom leaves him
+for a moment; but even when exhausted<span class='pagenum'><a name="Page_9" id="Page_9">[9]</a></span>
+nature seizes a small portion of sleep, the
+motion becomes so violent as not only to
+shake the bed-hangings, but even the floor
+and sashes of the room. The chin is now
+almost immoveably 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. The urine
+and f&aelig;ces are passed involuntarily; and at
+the last, constant sleepiness, with slight delirium,
+and other marks of extreme exhaustion,
+announce the wished-for release.</p>
+
+
+<h4><span class="smcap">Case I.</span></h4>
+
+<p>Almost every circumstance noted in the
+preceding description, was observed in a case
+which occurred several years back, and
+which, from the particular 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;
+excited an eager wish to acquire
+some further knowledge of its nature and
+cause.<span class='pagenum'><a name="Page_10" id="Page_10">[10]</a></span></p>
+
+<p>The subject of this case was a man rather
+more than fifty years of age, who had industriously
+followed the business of a gardener,
+leading a life of remarkable temperance
+and sobriety. The commencement of
+the malady was first manifested by a slight
+trembling of the left hand and arm, a circumstance
+which he was disposed to attribute
+to his having been engaged for several
+days in a kind of employment requiring
+considerable exertion of that limb. Although
+repeatedly questioned, he could recollect no
+other circumstance which he could consider
+as having been likely to have occasioned his
+malady. He had not suffered much from
+Rheumatism, or been subject to pains of the
+head, or had ever experienced any sudden
+seizure which could be referred to apoplexy
+or hemiplegia. In this case, every circumstance
+occurred which has been mentioned
+in the preceding history.</p>
+
+
+<h4><span class="smcap">Case II.</span></h4>
+
+<p>The subject of the case which was next
+noticed was casually met with in the street.
+It was a man sixty-two years of age; the<span class='pagenum'><a name="Page_11" id="Page_11">[11]</a></span>
+greater part of whose life had been spent as
+an attendant at a magistrate's office. He
+had suffered from the disease about eight or
+ten years. All the extremities were considerably
+agitated, the speech was very much
+interrupted, and the body much bowed
+and shaken. He 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. He described the disease
+as having come on very gradually, and
+as being, according to his full assurance, the
+consequence of considerable irregularities in
+his mode of living, and particularly of indulgence
+in spirituous liquors. He was the
+inmate of a poor-house of a distant parish,
+and being fully assured of the incurable nature
+of his complaint, declined making any
+attempts for relief.</p>
+
+
+<h4><span class="smcap">Case III.</span></h4>
+
+<p>The next case was also noticed casually
+in the street. The subject of it was a man
+of about sixty-five years of age, of a remarkable
+athletic frame. The agitation of the
+limbs, and indeed of the head and of the
+whole body, was too vehement to allow it<span class='pagenum'><a name="Page_12" id="Page_12">[12]</a></span>
+to be designated as trembling. 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. He stated, that he
+had been a sailor, and attributed his complaints
+to having been for several months
+confined in a Spanish prison, where he had,
+during the whole period of his confinement,
+lain upon the bare damp earth. The disease
+had here continued so long, and made
+such a progress, as to afford little or no prospect
+of relief. He besides was a poor
+mendicant, requiring as well as the means
+of medical experiment, those collateral aids
+which he could only obtain in an hospital.
+He was therefore recommended to make
+trial if any relief could, in that mode, be
+yielded him. The poor man, however, appeared
+to be by no means disposed to make
+the experiment.<span class='pagenum'><a name="Page_13" id="Page_13">[13]</a></span></p>
+
+
+<h4><span class="smcap">Case IV.</span></h4>
+
+<p>The next case which presented itself was
+that of a gentleman about fifty-five years,
+who had first experienced the trembling of
+the arms about five years before. His application
+was on account of a considerable
+degree of inflammation over the lower ribs
+on the left side, which terminated in the
+formation of matter beneath the fascia.
+About a pint was removed on making the
+necessary opening; and a considerable
+quantity discharged daily for two or three
+weeks. On his recovery from this, no
+change appeared to have taken place in his
+original complaint; and the opportunity of
+learning its future progress was lost by his
+removal to a distant part of the country.</p>
+
+
+<h4><span class="smcap">Case V.</span></h4>
+
+<p>In another case, the particulars of which
+could not be obtained, and the gentleman,
+the lamented subject of which was only seen
+at a distance, one of the characteristic symptoms
+of this malady, the inability for motion,
+except in a running pace, appeared to
+exist in an extraordinary degree. It seemed<span class='pagenum'><a name="Page_14" id="Page_14">[14]</a></span>
+to be necessary that the gentleman should
+be supported by his attendant, 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, after his having run about twenty
+paces.</p>
+
+
+<h4><span class="smcap">Case VI.</span></h4>
+
+<p>In a case which presented itself to observation
+since those above-mentioned, every
+information as to the progress of the malady
+was very readily obtained. The gentleman
+who was the subject of it is seventy-two
+years of age. He has led a life of temperance,
+and has never been exposed to any
+particular situation or circumstance which
+he can conceive likely to have occasioned,
+or disposed to this complaint; which he
+rather seems to regard as incidental upon his
+advanced age, than as an object of medical
+attention. He however recollects, that
+about twenty years ago, he was troubled<span class='pagenum'><a name="Page_15" id="Page_15">[15]</a></span>
+with lumbago, which was severe and lasted
+some time. About eleven or twelve, or
+perhaps more, years ago, he first perceived
+weakness in the left hand and arm, and
+soon after found the trembling commence.
+In about three years afterwards the right
+arm became affected in a similar manner:
+and soon afterwards the convulsive motions
+affected the whole body, and began to interrupt
+the speech. In about three years
+from that time the legs became affected.
+Of late years the action of the bowels
+had been very much retarded; and at
+two or three different periods had, with
+great difficulty, been made to yield to the
+action of very strong cathartics. But
+within the last twelvemonths this difficulty
+has not been so great; perhaps owing to
+an increased secretion of mucus, which envelopes
+the passing f&aelig;ces, and which precedes
+and follows their discharge in considerable
+quantity.</p>
+
+<p>About a year since, on waking in the
+night, he found that he had nearly lost the
+use of the right side, and that the face was
+much drawn to the left side. His medical<span class='pagenum'><a name="Page_16" id="Page_16">[16]</a></span>
+attendant saw him the following day,
+when he found him languid, with a small
+and quick pulse, and without pain in the
+head or disposition to sleep. Nothing more
+therefore was done than to promote the
+action of the bowels, and apply a blister
+to the back of the neck, and in about a
+fortnight the limbs had entirely recovered
+from their palsied state. During the time
+of their having remained in this state, neither
+the arm nor the leg of the paralytic
+side was in the least affected with the tremulous
+agitation; but as their paralysed
+state was removed, the shaking returned.</p>
+
+<p>At present he is almost constantly troubled
+with the agitation, which he describes
+as generally commencing in a slight degree,
+and gradually increasing, until it arises to
+such a height as to shake the room; when,
+by a sudden and somewhat violent change
+of posture, he is almost always able to stop
+it. But very soon afterwards it will commence
+in some other limb, in a small degree,
+and gradually increase in violence;
+but he does not remember the thus checking
+of it, to have been followed by any injurious<span class='pagenum'><a name="Page_17" id="Page_17">[17]</a></span>
+effect. When the agitation had not been
+thus interrupted, he stated, that it gradually
+extended through all the limbs, and at
+last affected the whole trunk. To illustrate
+his observation as to the power of suspending
+the motion by a sudden change of
+posture, he, being then just come in from
+a walk, with every limb shaking, threw
+himself rather violently into a chair, and
+said, &#8220;Now I am as well as ever I was in
+my life.&#8221; The shaking completely stopped;
+but returned within two minutes' time.</p>
+
+<p>He now possessed but little power in
+giving a required direction to the motions
+of any part. He was scarcely able to feed
+himself. He had written hardly intelligibly
+for the last three years; and at present
+could not write at all. His attendants observed,
+that of late the trembling would
+sometimes begin in his sleep, and increase
+until it awakened him: when he always
+was in a state of agitation and alarm.</p>
+
+<p>On being asked if he walked under much
+apprehension of falling forwards? he said he
+suffered much from it; and replied in the<span class='pagenum'><a name="Page_18" id="Page_18">[18]</a></span>
+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.</p>
+
+<p>The preceding 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.</p>
+
+
+
+<h2 style="padding-bottom: 0em"><a name="CHAP_II" id="CHAP_II"></a>CHAP. II.<span class='pagenum'><a name="Page_19" id="Page_19">[19]</a></span></h2>
+
+<h3>PATHOGNOMONIC SYMPTOMS EXAMINED&mdash;<i>TREMOR<br />
+COACTUS</i>&mdash;<i>SCELOTYRBE FESTINANS</i>.</h3>
+
+
+<p><span class="smcap">It</span> has been seen in the preceding history
+of the disease, and in the accompanying
+cases, that certain affections, the tremulous
+agitations, and the almost invincible propensity
+to run, when wishing only to walk,
+each of which has been considered by nosologists
+as distinct diseases, appear to be
+pathognomonic symptoms of this malady.
+To determine in which of these points of
+view these affections ought to be regarded,
+an examination into their nature, and an inquiry
+into the opinions of preceding writers
+respecting them, seem necessary to be attempted.</p>
+
+<hr />
+
+<p>I. <i>Involuntary tremulous motion, with lessened voluntary
+muscular power, in parts, not in action, and even supported.</i></p>
+
+<p><span class="smcap">It</span> is necessary that the peculiar nature of
+this tremulous motion should be ascertained,
+as well for the sake of giving to it its proper<span class='pagenum'><a name="Page_20" id="Page_20">[20]</a></span>
+designation, as for assisting in forming probable
+conjectures, as to the nature of the
+malady, which it helps to characterise.
+Tremors were distinguished by Juncker into
+Active, those proceeding from sudden affection
+of the minds, as terror, anger, &amp;c. and
+Passive, dependant on debilitating causes,
+such as advanced age, palsy, &amp;c<a name="FNanchor_2_2" id="FNanchor_2_2"></a><a href="#Footnote_2_2" class="fnanchor">[2]</a>. But a
+much more satisfactory and useful distinction
+is made by Sylvius de la Bo&euml; into those
+tremors which are produced by attempts at
+voluntary motion, and those which occur
+whilst the body is at rest<a name="FNanchor_3_3" id="FNanchor_3_3"></a><a href="#Footnote_3_3" class="fnanchor">[3]</a>. Sauvages distinguishes
+the latter of these species (<i>Tremor
+<span class='pagenum'><a name="Page_21" id="Page_21">[21]</a></span>Coactus</i>) by observing, that the tremulous
+parts leap, and as it were vibrate, even when
+supported: whilst every other tremor, he
+observes, ceases, when the voluntary exertion
+for moving the limb stops, or the part is
+supported, but returns when we will the limb
+to move; whence, he says, tremor is distinguished
+from every other kind of spasm<a name="FNanchor_4_4" id="FNanchor_4_4"></a><a href="#Footnote_4_4" class="fnanchor">[4]</a>.</p>
+
+<p>A small degree of attention will be sufficient
+to perceive, that Sauvages, by this just
+distinction, actually separates this kind of
+tremulous motion, and which is the kind
+peculiar to this disease, from the Genus Tremor.
+In doing this he is fully warranted
+by the observations of Galen on the same
+subject, as noticed by Van Swieten<a name="FNanchor_5_5" id="FNanchor_5_5"></a><a href="#Footnote_5_5" class="fnanchor">[5]</a>.
+&#8220;Binas has tremoris species<a name="FNanchor_6_6" id="FNanchor_6_6"></a><a href="#Footnote_6_6" class="fnanchor">[6]</a> Galenus subtiliter
+<span class='pagenum'><a name="Page_22" id="Page_22">[22]</a></span>distinxit, atque etiam diversis nominibus
+insignivit, tremor enim (&#964;&#1009;&#8001;&#956; &amp;) facultatis
+corpus moventis et vehentis infirmitate oboritur.
+Quippe nemo, qui artus movere
+non instituerit tremet. Palpitantes autem
+partes, etiam in quiete fuerint, etiamsi nullum
+illis motum induxeris palpitant. Ideo
+primam (<i>posteriorem</i>) modo descriptam tremoris
+speciem, quando quiescenti homini
+involuntariis illis et alternis motibus agitantur
+membra, palpitationem (&#960;&#7937;&#955;&#956;&#959;&#957;) dixit,
+posteriorem (<i>primam</i>) vero, qu&aelig; non fit
+nisi homo conetur partes quasdam movere
+tremorem vocavit.&#8221;</p>
+
+<p>Under this authority the term palpitation
+may be employed to mark those morbid
+motions which chiefly characterise this disease,
+notwithstanding that this term has
+been anticipated by Sauvages, as characteristic
+of another species of tremor<a name="FNanchor_7_7" id="FNanchor_7_7"></a><a href="#Footnote_7_7" class="fnanchor">[7]</a>. The
+<span class='pagenum'><a name="Page_23" id="Page_23">[23]</a></span>separation of palpitation of the limbs (<i>Palmos</i>
+of Galen, <i>Tremor Coactus</i> of de la Bo&euml;) from
+tremor, is the more necessary to be insisted
+on, since the distinction may assist in
+leading to a knowledge of the seat of the
+disease. It is also necessary to bear in mind,
+that this affection is distinguishable from
+tremor, by the agitation, in the former, occurring
+whilst the affected part is supported
+and unemployed, and being even checked
+by the adoption of voluntary motion; whilst
+in the latter, the tremor is induced immediately
+on bringing the parts into action.
+Thus an artist, afflicted with the malady
+here treated of, whilst his hand and arm is
+palpitating strongly, will seize his pencil,
+and the motions will be suspended, allowing
+<span class='pagenum'><a name="Page_24" id="Page_24">[24]</a></span>him to use it for a short period; but
+in tremor, if the hand be quite free from
+the affection, should the pen or pencil be
+taken up, the trembling immediately commences.</p>
+
+<hr />
+
+<p>II. <i>A propensity to bend the trunk forwards, and to pass from
+a walking to a running pace.</i></p>
+
+<p><span class="smcap">This</span> affection, which observation seems to
+authorise the being considered as a symptom
+peculiar to this disease, has been mentioned
+by few nosologists: it appears to
+have been first noticed by Gaubius, who
+says, &#8220;Cases occur in which the muscles duly
+excited into action by the impulse of the
+will, do then, with an unbidden agility, and
+with an impetus not to be repressed, accelerate
+their motion, and run before the unwilling
+mind. It is a frequent fault of the
+muscles belonging to speech, nor yet of
+these alone: I have seen one, who was able
+to run, but not to walk<a name="FNanchor_8_8" id="FNanchor_8_8"></a><a href="#Footnote_8_8" class="fnanchor">[8]</a>.&#8221;</p>
+<p><span class='pagenum'><a name="Page_25" id="Page_25">[25]</a></span></p>
+<p>Sauvages, referring to this symptom, says,
+another disease which has been very rarely
+seen by authors, appears to be referable to
+the same genus (Scelotyrbe, of which he
+makes <i>Chorea sancti viti</i> the first species);
+which, he says, &#8220;I think cannot be more fitly
+named than hastening or hurrying Scelotyrbe
+(<i>Scelotyrbem festinantem, seu festiniam</i>).&#8221;</p>
+
+<p><i>Scelotyrbe festinans</i>, he says, is a peculiar
+species of scelotyrbe, in which the patients,
+whilst wishing to walk in the ordinary
+mode, are forced to run, which has been
+seen by Carguet and by the illustrious
+Gaubius; a similar affection of the speech,
+when the tongue thus outruns the mind, is
+termed volubility. Mons. de Sauvages attributes
+this complaint to a want of flexibility
+in the muscular fibres. Hence, he supposes,
+that the patients make shorter steps, and
+strive with a more than common exertion or
+impetus to overcome the resistance; walking
+with a quick and hastened step, as if
+hurried along against their will. <i>Chorea Viti</i>,
+<span class='pagenum'><a name="Page_26" id="Page_26">[26]</a></span>he says, attacks the youth of both sexes, but
+this disease only those advanced in years;
+and adds, that it has hitherto happened to
+him to have seen only two of these cases;
+and that he has nothing to offer respecting
+them, either in theory or practice<a name="FNanchor_9_10" id="FNanchor_9_10"></a><a href="#Footnote_9_10" class="fnanchor">[9]</a>.</p>
+
+<p>Having made the necessary inquiries respecting
+these two affections, <i>Tremor coactum</i>
+of Sylvius de la Bo&euml; and of Sauvages, and
+<i>Scelotyrbe festinans</i> of the latter nosologist,
+which appear to be characteristic symptoms
+of this disease, it becomes necessary, in the
+next place, to endeavour to distinguish this
+disease from others which may bear a resemblance
+to it in some particular respects.</p>
+
+
+
+<h2 style="padding-bottom: 0em"><a name="CHAP_III" id="CHAP_III"></a>CHAP. III.<span class='pagenum'><a name="Page_27" id="Page_27">[27]</a></span></h2>
+
+<h3>SHAKING PALSY DISTINGUISHED FROM
+OTHER DISEASES WITH<br /> WHICH IT MAY BE
+CONFOUNDED.</h3>
+
+
+<p><span class="smcap">Treating</span> of a disease resulting from an
+assemblage of symptoms, some of which do
+not appear to have yet engaged the general
+notice of the profession, particular care
+is required whilst endeavouring to mark its
+diagnostic characters. It is sufficient, in
+general, to point out the characteristic differences
+which are observable between diseases
+in some respects resembling each
+other. But in this case more is required:
+it is necessary to show that it is a disease<span class='pagenum'><a name="Page_28" id="Page_28">[28]</a></span>
+which does not accord with any which
+are marked in the systematic arrangements
+of nosologists; and that the name by
+which it is here distinguished has been hitherto
+vaguely applied to diseases very different
+from each other, as well as from that
+to which it is now appropriated.</p>
+
+<p>Palsy, either consequent to compression
+of the brain, or dependent on partial exhaustion
+of the energy of that organ, may, when
+the palsied limbs become affected with tremulous
+motions, be confounded with this disease.
+In those cases the abolition or diminution
+of voluntary muscular action takes
+place suddenly, the sense of feeling being
+sometimes also impaired. But in this disease,
+the diminution of the influence of the
+will on the muscles comes on with extreme
+slowness, is always accompanied, and even
+preceded, by agitations of the affected parts,
+and never by a lessened sense of feeling.
+The dictates of the will are even, in the last
+stages of the disease, conveyed to the muscles;
+and the muscles act on this impulse,
+but their actions are perverted.</p>
+
+<p>Anomalous cases of convulsive affections<span class='pagenum'><a name="Page_29" id="Page_29">[29]</a></span>
+have been designated by the term Shaking
+Palsy: a term which appears to be improperly
+applied to these cases, independent
+of the want of accordance between them
+and that disease which has been here denominated
+Shaking Palsy. Dr. Kirkland, in
+his commentary on Apoplectic and Paralytic
+Affections, &amp;c. cites the following case, related
+by Dr. Charlton, as belonging, he says,
+to the class of Shaking Palsies. &#8220;Mary
+Ford, of a sanguineous and robust constitution,
+had an involuntary motion of her right
+arm, occasioned by a fright, which first
+brought on convulsion fits, and most excruciating
+pain in the stomach, which vanished
+on a sudden, and her right arm was instantaneously
+flung into an involuntary and
+perpetual motion, like the swing of a pendulum,
+raising the hand, at every vibration
+higher than her head; but if by any means
+whatever it was stopped; the pain in her
+stomach came on again, and convulsion fits
+were the certain consequence, which went
+off when the vibration of her hand returned.&#8221;</p>
+
+<p>Another case, which the Doctor designates
+as 'A Shaking Palsy,' apparently from worms,
+he describes thus, &#8220;A poor boy, about<span class='pagenum'><a name="Page_30" id="Page_30">[30]</a></span>
+twelve or thirteen years of age, was seized
+with a Shaking Palsy. His legs became
+useless, and together with his head and
+hands, were in continual agitation; after
+many weeks trial of various remedies, my
+assistance was desired.</p>
+
+<p>&#8220;His bowels being cleared, I ordered
+him a grain of Opium a day in the gum
+pill; and in three or four days the shaking
+had nearly left him.&#8221; By pursuing this
+plan, the medicine proving a vermifuge, he
+could soon walk, and was restored to perfect
+health.</p>
+
+<p>Whether these cases should be classed
+under Shaking Palsy or not, is necessary
+to be here determined; since, if they are
+properly ranked, the cases which have been
+described in the preceding pages, differ so
+much from them as certainly to oppose their
+being classed together: and the disease,
+which is the subject of these pages, cannot
+be considered as the same with Shaking
+Palsy, as characterised by those cases.</p>
+
+<p>The term Shaking Palsy is evidently inapplicable
+to the first of these cases, which<span class='pagenum'><a name="Page_31" id="Page_31">[31]</a></span>
+appears to have belonged more properly to
+the genus <i>Convulsio</i>, of Cullen, or to <i>Hieranosos</i>
+of Linn&aelig;us and Vogel<a name="FNanchor_10_11" id="FNanchor_10_11"></a><a href="#Footnote_10_11" class="fnanchor">[10]</a>.</p>
+
+<p>The latter appears to be referable to that
+class of proteal forms of disease, generated
+by a disordered state of prim&aelig; vi&aelig;, sympathetically
+<span class='pagenum'><a name="Page_32" id="Page_32">[32]</a></span>affecting the nervous influence in
+a distant part of the body.</p>
+
+<p>Unless attention is paid to one circumstance,
+this disease will be confounded with
+those species of passive tremblings to which
+the term Shaking Palsies has frequently been
+applied. These are, <i>tremor temulentus</i>, the
+trembling consequent to indulgence in the
+drinking of spirituous liquors; that which
+proceeds from the immoderate employment
+of tea and coffee; that which appears to be
+dependent on advanced age; and all those
+tremblings which proceed from the various
+circumstances which induce a diminution of
+power in the nervous system. But by attending
+to that circumstance alone, which
+has been already noted as characteristic of
+mere tremor, the distinction will readily
+be made. If the trembling limb be supported,
+and none of its muscles be called
+into action, the trembling will cease. In
+the real Shaking Palsy the reverse of this
+takes place, the agitation continues in full
+force whilst the limb is at rest and unemployed;
+and even is sometimes diminished
+by calling the muscles into employment.</p>
+
+
+
+<h2 style="padding-bottom: 0em"><a name="CHAP_IV" id="CHAP_IV"></a>CHAP. IV.<span class='pagenum'><a name="Page_33" id="Page_33">[33]</a></span></h2>
+
+<h3>PROXIMATE CAUSE&mdash;REMOTE CAUSES&mdash;ILLUSTRATIVE
+CASES.</h3>
+
+
+<p><span class="smcap">Before</span> making the attempt to point out the
+nature and cause of this disease, it is necessary
+to plead, that it is made under very unfavourable
+circumstances. Unaided by previous
+inquiries immediately directed to this
+disease, and not having had the advantage,
+in a single case, of that light which anatomical
+examination yields, opinions and
+not facts can only be offered. Conjecture
+founded on analogy, and an attentive consideration
+of the peculiar symptoms of the
+disease, have been the only guides that could
+be obtained for this research, the result of
+which is, as it ought to be, offered with hesitation.</p>
+
+<h4>SUPPOSED PROXIMATE CAUSE.</h4>
+
+<div class="blockquot">
+
+<p>A diseased state of the <i>medulla spinalis</i>, in
+that part which is contained in the
+canal, formed by the superior cervical<span class='pagenum'><a name="Page_34" id="Page_34">[34]</a></span>
+vertebr&aelig;, and extending, as the disease
+proceeds, to the <i>medulla oblongata</i>.</p></div>
+
+<p>By the nature of the symptoms we are
+taught, that the disease depends on some
+irregularity in the direction of the nervous
+influence; by the wide range of parts
+which are affected, that the injury is rather
+in the source of this influence than merely
+in the nerves of the parts; by the situation
+of the parts whose actions are impaired, and
+the order in which they become affected, that
+the proximate cause of the disease is in the
+superior part of the medulla spinalis; and by
+the absence of any injury to the senses and
+to the intellect, that the morbid state does
+not extend to the encephalon.</p>
+
+<p>Uncertainty existing as to the nature of
+the proximate cause of this disease, its remote
+causes must necessarily be referred to
+with indecision. Assuming however the
+state just mentioned as the proximate cause,
+it may be concluded that this may be the
+result of injuries of the medulla itself, or of
+the theca helping to form the canal in which
+it is inclosed.<span class='pagenum'><a name="Page_35" id="Page_35">[35]</a></span></p>
+
+<p>The great degree of mobility in that portion
+of the spine which is formed by the
+superior cervical vertebr&aelig;, must render it,
+and the contained parts, liable to injury from
+sudden distortions. Hence therefore may
+proceed inflammation of quicker or of slower
+progress, disease of the vertebr&aelig;, derangement
+of structure in the medulla, or in its
+membranes, thickening or even ulceration
+of the theca, effusion of fluids, &amp;c.</p>
+
+<p>But in no case which has been noticed,
+has the patient recollected receiving any
+injury of this kind, or any fixed pain in
+early life in these parts, which might have
+led to the opinion that the foundation for
+this malady had been thus laid. On the
+subject indeed of remote causes, no satisfactory
+accounts has yet been obtained
+from any of the sufferers. Whilst one has
+attributed this affliction to indulgence in
+spirituous liquors, and another to long lying
+on the damp ground; the others have been
+unable to suggest any circumstance whatever,
+which, in their opinion, could be considered
+as having given origin, or disposed,
+to the calamity under which they suffered.<span class='pagenum'><a name="Page_36" id="Page_36">[36]</a></span></p>
+
+<p>Cases illustrative of the nature and cause
+of this malady are very rare. In the following
+case symptoms very similar are observable,
+so far as affecting the lower extremities.
+That the medulla spinalis was here
+affected, and in its lower part, is not to be
+doubted: but this, unfortunately, was never
+ascertained by examination. It must be
+however remarked, that this case differed
+from those which have been given of this
+disease, in the suddenness with which the
+symptoms appeared.</p>
+
+<p><i>A.&nbsp;B.</i> aged twenty-six years, during a
+course of mercury for a venereal affection,
+was exposed to severely inclement weather,
+for several hours, and the next morning,
+complained of extreme pain in the back,
+and of total inability to employ voluntarily
+the muscles of the lower extremities, which
+were continually agitated with severe convulsive
+motions. The physician who attended
+him employed those means which
+seemed best calculated to relieve him; but
+with no beneficial effect. The lower extremities
+were perpetually agitated with
+strong palpitatory motions, and, frequently,<span class='pagenum'><a name="Page_37" id="Page_37">[37]</a></span>
+three or four times in a minute, suddenly
+raised with great vehemence two or three
+feet from the ground, either in a forward
+or oblique direction, striking one limb against
+the other, or against the chairs, tables, or
+any substance which stood in the way. To
+check these inordinate motions, no means
+were in the least effectual, except striking
+the thighs forcibly during the more violent
+convulsions. No advantage was derived from
+all the means which were employed during
+upwards of twelvemonths. Full ten years
+after this period, the unhappy subject of
+this malady 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.</p>
+
+<p>It must be acknowledged, that in the
+well-known cases, described by Mr. Potts,
+of that kind of Palsy of the lower limbs
+which is frequently found to accompany
+a curvature of the spine, and in which
+a carious state of the vertebr&aelig; is found
+to exist, no instructive analogy is discoverable;
+slight convulsive motions may indeed<span class='pagenum'><a name="Page_38" id="Page_38">[38]</a></span>
+happen in the disease proceeding from
+curvature of the spine; but palpitating motions
+of the limbs, such as belong to the
+disease here described, do not appear to have
+been hitherto noticed.</p>
+
+<p>Whilst striving to determine the nature
+and origin of this disease, it becomes necessary
+to give the following particulars of an interesting
+case of Palsy occasioned by a fall,
+attended with uncommon symptoms, related
+by Dr. Maty, in the third volume of
+the Medical Observations and Inquiries.
+The subject of this case, the Count de
+Lordat, had the misfortune to be overturned
+from a pretty high and steep bank.
+His head pitched against the top of the
+coach, and was bent from left to right;
+his left shoulder, arm, and especially his
+hand, were considerably bruised. At first
+he felt a good deal of pain along the left side
+of his neck, but neither then, nor at any
+other time, had he any faintings, vomitings,
+or giddiness.&mdash;On the sixth day he was
+let blood, on account of the pain in his
+shoulder and the contusion of his hand,
+which were then the only symptoms he<span class='pagenum'><a name="Page_39" id="Page_39">[39]</a></span>
+complained of, and of which he soon found
+himself relieved.&mdash;Towards the beginning
+of the following winter, he began to find
+<i>a small impediment in uttering some words, and
+his left arm appeared weaker</i>. In the following
+spring, having suffered considerably from the
+severities of the winter campaign, he found
+<i>the difficulty in speaking, and in moving his left
+arm, considerably increased</i>.&mdash;On employing
+the thermal waters of Bourbonne, his speech
+become freer, but, on his return to Paris,
+the Palsy was increased, and the arm somewhat
+wasted.&mdash;In the beginning of the next
+spring he went to Balaruc; when he became
+affected with <i>involuntary convulsive
+motions all over the body</i>. The left arm
+withered more and more, <i>a spitting began</i>,
+and now it was <i>with difficulty that he uttered a
+few words</i>. Frictions and sinapisms were
+successively tried, and an issue, made by a
+caustic, was kept open for some time without
+any effect; but no mention is made
+of what part the issue was established in.</p>
+
+<p>Soon after this, and three years and a half
+after the fall, Doctor Maty first saw the patient,
+and gives the following description of<span class='pagenum'><a name="Page_40" id="Page_40">[40]</a></span>
+his situation. &#8220;A more melancholy object
+I never beheld. The patient, naturally a
+handsome, middle-sized, sanguine man, of
+a cheerful disposition, and an active mind,
+appeared much emaciated, stooping, and
+dejected. <i>He still walked alone with a cane,
+from one room to the other, but with great difficulty,
+and in a tottering manner</i>; his left
+hand and arm were much reduced, and
+would hardly perform any motion; <i>the
+right was somewhat benumbed, and he could
+scarcely lift it up to his head; his saliva was
+continually trickling out of his mouth, and he
+had neither the power of retaining it, nor of
+spitting it out freely</i>. What words he still
+could utter were monosyllables, and these
+came out, after much struggle, in a violent
+expiration, and with such a low voice and
+indistinct articulation, as hardly to be understood
+but by those who were constantly
+with him. He fetched his breath rather
+hard; his pulse was low, but neither accelerated
+nor intermitting. He took very little
+nourishment, could chew and swallow
+no solids, and even found great pain in getting
+down liquids. Milk was almost his only
+food; his body was rather loose, his urine<span class='pagenum'><a name="Page_41" id="Page_41">[41]</a></span>
+natural, his sleep good, his senses, and the
+powers of his mind, unimpaired; he was
+attentive to, and sensible of every thing
+which was said in conversation, and shewed
+himself very desirous of joining in it; but
+was continually checked by the impediment
+in his speech, and the difficulty which his
+hearers were put to. Happily for him he
+was able to read, and as capable as ever of
+writing, as he shewed me, by putting into
+my hands an account of his present situation,
+drawn up by himself: and I am informed
+that he spent his time to the very
+last, in writing upon some of the most abstruse
+subjects.&#8221;</p>
+
+<p>This gentleman died about four years
+after the accident, when the body was examined
+by Dr. Bellett and Mons. Sorbier, who
+made the following report:</p>
+
+<p>&#8220;We first examined the muscles of the
+tongue, which were found extenuated and
+of a loose texture. We observed no signs
+of compression in the lingual and brachial
+nerves, as high as their exit from the basis
+of the cranium and the vertebr&aelig; of the neck;<span class='pagenum'><a name="Page_42" id="Page_42">[42]</a></span>
+but they appeared to us more compact than
+they commonly are, being nearly tendinous.
+The dura mater was in a sound state, but
+the pia mater was full of blood and lymph;
+on it several hydatids, and towards the
+falx some marks of suppuration were observed.
+The ventricles were filled with
+water, and the plexus choroides was considerably
+enlarged, and stuffed with grumous
+blood. The cortical surface of the brain
+appeared much browner than usual, but
+neither the medullary part nor cerebellum
+were impaired. We chiefly took notice of
+the Medulla Oblongata, this was greatly
+enlarged, surpassing the usual size by more
+than one third. It was likewise more compact.
+The membranes, which, in their continuation,
+inclose the spinal marrow, were
+so tough that we found great difficulty
+in cutting through them, and we observed
+this to be the cause of the tendinous texture
+of the cervical nerves. The marrow itself
+had acquired such solidity as to elude the
+pressure of our fingers, it resisted as a callous
+body, and could not be bruised. This hardness
+was observed all along the vertebr&aelig;
+of the neck, but lessened by degrees, and<span class='pagenum'><a name="Page_43" id="Page_43">[43]</a></span>
+was not near so considerable in the vertebr&aelig;
+of the thorax. Though the patient
+was but nine and thirty years old, the cartilages
+of the sternum were ossified, and required
+as much labour to cut them asunder
+as the ribs; like these they were spungy,
+but somewhat whiter. The lungs and heart
+were sound. At the bottom of the stomach
+appeared an inflammation, which increased
+as it extended to the intestines. The ileum
+looked of that dark and livid hue, which
+is observed in membranous parts tending
+to mortification. The colon was not above
+an inch in diameter, the rectum was smaller
+still, but both appeared sound.&mdash;From these
+appearances, we were at no loss to fix the
+cause of this gradual palsy in the alteration
+of the medulla spinalis and oblongata.&#8221;</p>
+
+<p>Dr. Bellett offers the following explanation
+of these changes. &#8220;I conceive, that, by
+this accident, the head being violently bent
+to the right, the nervous membranes on
+the left were excessively stretched and
+irritated; that this cause extended by degrees
+to the spinal marrow, which being<span class='pagenum'><a name="Page_44" id="Page_44">[44]</a></span>
+thereby compressed, brought on the paralytic
+symptoms, not only of the left arm,
+but at last in some measure also of the right.
+This induration seems to have been occasioned
+by the constant afflux of the nutritive
+juices, which were stopt at that place, and
+deprived of their most liquid parts; the
+grosser ones being unable to spread in the
+boney cavity, by which they were confined,
+could only acquire a greater solidity, and
+change a soft body into a hard and nearly
+osseous mass. This likewise accounts for
+the increase of the medulla oblongata, which
+being loaded with more juices than it could
+send off, swelled in the same manner as the
+branches of trees, which will grow of a monstrous
+size, when the sap that runs into them
+is stopt in its progress. The medulla oblongata
+not growing so hard as the spinalis,
+was doubtless owing to its not being confined
+in an osseous theca, but surrounded
+with soft parts, which allowed it room to
+spread. The obstruction from the bulk of
+this substance must have affected the brain,
+and probably induced the thickening of
+the pia mater, the hydatids, and the beginning
+of suppuration, whereas the dura<span class='pagenum'><a name="Page_45" id="Page_45">[45]</a></span>
+mater, being of a harder texture, was not
+injured<a name="FNanchor_11_12" id="FNanchor_11_12"></a><a href="#Footnote_11_12" class="fnanchor">[11]</a>.&#8221;</p>
+
+<p>In some of the symptoms which appeared
+in this case, an agreement is observable between
+it and those cases which are mentioned
+in the beginning of these pages. The
+weakened state of both arms; the power first
+lessening in one arm, and then in a similar
+manner in the other arm; the affection of
+the speech; the difficulty in chewing and
+in swallowing; as well as of retaining, or
+freely discharging, the spittle; the convulsive
+motions of the body; and the unimpaired
+state of the intellects; constitute
+such a degree of accordance as, although
+it may not mark an identity of disease,
+serves at least to show that nearly the
+same parts were the seat of the disease in
+both instances. Thus we attain something
+like confirmation of the supposed proximate
+cause, and of one of the assumed occasional
+causes.</p>
+
+<p>Whilst conjecturing as to the cause of
+this disease, the following collected observations
+<span class='pagenum'><a name="Page_46" id="Page_46">[46]</a></span>on the effects of injury to the medulla
+spinalis, by Sir Everard Home, become
+particularly deserving of attention.
+It thence appears, that none of the characteristic
+symptoms of this malady are produced
+by compression, laceration, or complete
+division of the medulla spinalis.</p>
+
+<p>&#8220;Pressure upon the medulla spinalis of
+the neck, by coagulated blood, produced
+paralytic affections of the arms and legs;
+all the functions of the internal organs were
+carried on for thirty-five days, but the urine
+and stools passed involuntarily<a name="FNanchor_12_13" id="FNanchor_12_13"></a><a href="#Footnote_12_13" class="fnanchor">[12]</a>.</p>
+
+<p>&#8220;Blood extravasated in the central part of
+the medulla, in the neck, was attended with
+paralytic affection of the legs, but not of the
+arms<a name="FNanchor_13_14" id="FNanchor_13_14"></a><a href="#Footnote_13_14" class="fnanchor">[13]</a>.</p>
+
+<p><span class='pagenum'><a name="Page_47" id="Page_47">[47]</a></span></p><p>&#8220;In a case where the substance of the medulla
+was lacerated in the neck, there was
+a paralysis in all the parts below the laceration,
+the lining of the &#339;sophagus was so
+sensible, that solids could not be swallowed,
+on account of the pain they occasioned<a name="FNanchor_14_15" id="FNanchor_14_15"></a><a href="#Footnote_14_15" class="fnanchor">[14]</a>.</p>
+
+<p>&#8220;When the medulla of the back was completely
+divided, there was momentary loss
+of sight, loss of memory for fifteen minutes,
+and permanent insensibility in all the lower
+parts of the body. The skin above the
+division of the spinal marrow perspired, that
+below did not. The wounded spinal marrow
+appeared to be extremely sensible<a name="FNanchor_15_16" id="FNanchor_15_16"></a><a href="#Footnote_15_16" class="fnanchor">[15]</a>.&#8221;
+<i>Philosophical Transactions</i>, 1816, p. 485.</p>
+
+<p>In two of the cases already noticed,
+symptoms of rheumatism had previously
+existed; and in Case IV. the right arm, in
+which the palpitation began, was said to
+<span class='pagenum'><a name="Page_48" id="Page_48">[48]</a></span>have been very violently affected with rheumatic
+pain to the fingers ends. The consideration
+of this case, in which the palpitation
+had been preceded, at a considerable distance
+of time, by this painful affection of the
+arm, led to the supposition that this latter
+circumstance might be the cause of the palpitations,
+and the other subsequent symptoms
+of this disease. This supposition naturally
+occasioned the attention to be eagerly fixed
+on the following case; and of course influenced
+the mode of treatment which was
+adopted.</p>
+
+<p><i>A.&nbsp;B.</i> subject to rheumatic affection of
+the deltoid muscle, had felt the usual inconveniences
+from it for two or three days;
+but at night found the pain had extended
+down the arm, along the inside of the
+fore-arm, and on the sides of the fingers, in
+which a continual tingling was felt. The
+pain, without being extremely intense, was
+such as effectually to prevent sleep: and
+seemed to follow the course of the brachial
+nerve. Whilst ascertaining the propriety of
+this conclusion, the pain was found to ramify,
+as it were, on the fore and back part of the<span class='pagenum'><a name="Page_49" id="Page_49">[49]</a></span>
+chest; and was slightly augmented by drawing
+a deep breath.</p>
+
+<p>These circumstances suggested the probability
+of slight inflammation, or increased
+determination to the origin of the nerves of
+these parts, and to the neighbouring medulla.
+On this ground, blood was taken from the
+back part of the neck, by cupping; hot
+fomentations were applied for about the
+space of an hour, when the upper part of the
+back of the neck was covered with a blister,
+perspiration was freely induced by two or
+three small doses of antimonials, and the following
+morning the bowels were evacuated
+by an appropriate dose of calomel. On the
+following day the pains were much diminished,
+and in the course of four or five days
+were quite removed. The arm and hand felt
+now more than ordinarily heavy, and were
+evidently much weakened: aching, and feeling
+extremely wearied after the least exertion.
+The strength of the arm was not
+completely recovered at the end of more
+than twelvemonths; and, after more than
+twice that time, exertion would excite the
+feeling of painful weariness, but no palpitation<span class='pagenum'><a name="Page_50" id="Page_50">[50]</a></span>
+or other unpleasant symptom has occurred
+during the five or six years which
+have since passed.</p>
+
+<p>The commencement, progress, and termination
+of this attack; with the success
+attending the mode of treatment, and the
+symptoms which followed, seem to lead to
+the conjecture, that the proximate cause of
+the disease, in this case, existed in the medulla
+spinalis, and that it might, if neglected,
+have gradually resolved itself into that disease
+which is the object of our present inquiry.</p>
+
+<p>Some few months after the occurrence of
+the preceding case, the writer of these lines
+was called to a female about forty years of
+age, complaining of great pain in both the
+arms, extending from the shoulder to the
+finger ends. She stated, that she was attacked
+in the same manner as is described
+in the preceding case, about nine months
+before; that the complaint was considered
+as rheumatism, and was not benefited by
+any of the medicines which had been employed;
+but that after three or four weeks<span class='pagenum'><a name="Page_51" id="Page_51">[51]</a></span>
+it gradually amended, leaving both the arms
+and hands in a very weakened and trembling
+state. From this state they were now
+somewhat recovered; but she was extremely
+anxious, fearing that if the present attack
+should not be soon checked, she might
+entirely lose the use of her hands and arms.</p>
+
+<p>Instructed by the preceding case, similar
+means were here recommended. Leeches,
+stimulating fomentations, and a blister,
+which was made for sometime to yield a
+purulent discharge, were applied over the
+cervical vertebr&aelig;; and in the course of a
+very few days the pain was entirely removed.
+It is regretted that no farther information,
+as to the progress of this case,
+could be obtained.</p>
+
+<p>On meeting with these two cases, it was
+thought that it might not be improbable
+that attacks of this kind, considered at the
+time merely as rheumatic affections, might
+lay the foundation of this lamentable disease,
+which might manifest itself at some distant
+period, when the circumstance in which it
+had originated, had, perhaps, almost escaped<span class='pagenum'><a name="Page_52" id="Page_52">[52]</a></span>
+the memory. Indeed when it is considered
+that neither in the ordinary cases of Palsy
+of the lower extremities, proceeding from
+diseased spine, nor in cases of injured medulla
+from fractured vertebr&aelig;, any of the
+peculiar symptoms of this disease are observable,
+we necessarily doubt as to the probability
+of its being the direct effect of any
+sudden injury. But taking all circumstances
+into due consideration, particularly the very
+gradual manner in which the disease commences,
+and proceeds in its attacks; as well
+as the inability to ascribe its origin to any
+more obvious cause, we are led to seek for
+it in some slow morbid change in the structure
+of the medulla, or its investing membranes,
+or theca, occasioned by simple inflammation,
+or rheumatic or scrophulous
+affection.</p>
+
+<p>It must be too obvious that the evidence
+adduced as to the nature of the proximate
+and occasional causes of this disease, is by no
+means conclusive. A reference to the test
+therefore which will be yielded by an examination
+of some of the more prominent
+symptoms, especially as to their agreement<span class='pagenum'><a name="Page_53" id="Page_53">[53]</a></span>
+with the supposed proximate cause, is more
+particularly demanded. Satisfied as to the
+importance of this part of the present undertaking,
+no apology is offered for the extent
+to which the examination is carried
+on.</p>
+
+<p>If the palpitation and the attendant weakness
+of the limbs, &amp;c. be considered as to
+the order in which the several parts are attacked,
+it is believed, that some confirmation
+will be obtained of the opinion which has
+been just offered, respecting the cause, or at
+least the seat, of that change which may be
+considered as the proximate cause of this
+disease.</p>
+
+<p>One of the arms, in all the cases which
+have been here mentioned, has been the
+part in which these symptoms have been
+first noticed; the legs, head, and trunk have
+then become gradually affected, and lastly,
+the muscles of the mouth and fauces have
+yielded to the morbid influence.</p>
+
+<p>The arms, the parts first manifesting disordered
+action, of course direct us, whilst<span class='pagenum'><a name="Page_54" id="Page_54">[54]</a></span>
+searching for the cause of these changes, to
+the brachial nerves. But finding the mischief
+extending to other parts, not supplied
+with these, but with other nerves derived
+from nearly the same part of the medulla
+spinalis, we are of course led to consider
+that portion of the medulla spinalis itself,
+from which these nerves are derived, as the
+part in which those changes have taken
+place, which constitute the proximate cause
+of this disease.</p>
+
+<p>From the subsequent affection of the
+lower extremities, and from the failure of
+power in the muscles of the trunk, such a
+change in the substance of the medulla
+spinalis may be inferred, as shall have considerably
+interrupted, and interfered with,
+the extension of the nervous influence to
+those parts, whose nerves are derived from
+any portion of the medulla below the part
+which has undergone the diseased change.</p>
+
+<p>The difficulty in supporting the trunk
+erect, as well as the propensity to the adopting
+of a hurried pace, is also referable to
+such a diminution of the nervous power in<span class='pagenum'><a name="Page_55" id="Page_55">[55]</a></span>
+the extensor muscles of the head and trunk,
+as prevents them from performing the offices
+of maintaining the head and body in an erect
+position.</p>
+
+<p>From the impediment to speech, the difficulty
+in mastication and swallowing, the
+inability to retain, or freely to eject, the Saliva,
+may with propriety be inferred an extension
+of the morbid change upwards
+through the medulla spinalis to the medulla
+oblongata, necessarily impairing the powers
+of the several nerves derived from that portion
+into which the morbid change may have
+reached. In the late occurrence of this set
+of symptoms, and the extension upwards of
+the diseased state, a very close agreement
+is observable between this disease and that
+which has been already shown, proved fatal
+to the Count de Lordat. But in this case,
+the disease doubtlessly became differently
+modified, and its symptoms considerably accelerated,
+in consequence of the magnitude
+of the injury by which the disease was induced.</p>
+
+
+
+<h2 style="padding-bottom: 0em"><a name="CHAP_V" id="CHAP_V"></a>CHAP. V.<span class='pagenum'><a name="Page_56" id="Page_56">[56]</a></span></h2>
+
+<h3>CONSIDERATIONS RESPECTING THE MEANS
+OF CURE.</h3>
+
+
+<p><span class="smcap">The</span> inquiries made in the preceding pages
+yield, it is to be much regretted, but
+little more than evidence of inference: nothing
+direct and satisfactory has been obtained.
+All that has been ventured to assume
+here, has been that the disease depends
+on a disordered state of that part of
+the medulla which is contained in the cervical
+vertebr&aelig;. But of what nature that
+morbid change is; and whether originating
+in the medulla itself, in its membranes, or
+in the containing theca, is, at present, the
+subject of doubt and conjecture. But although,
+at present, uninformed as to the
+precise nature of the disease, still it ought
+not to be considered as one against which
+there exists no countervailing remedy.</p>
+
+<p>On the contrary, there appears to be sufficient
+reason for hoping that some remedial
+process may ere long be discovered, by which,
+at least, the progress of the disease may be<span class='pagenum'><a name="Page_57" id="Page_57">[57]</a></span>
+stopped. It seldom happens that the agitation
+extends beyond the arms within the
+first two years; which period, therefore,
+if we were disposed to divide the disease
+into stages, might be said to comprise the
+first stage. In this period, it is very probable,
+that remedial means might be employed
+with success: and even, if unfortunately
+deferred to a later period, they
+might then arrest the farther progress of
+the disease, although the removing of the
+effects already produced, might be hardly
+to be expected.</p>
+
+<p>From a review of the changes which had
+taken place in the case of Count de Lordat, it
+seems as if we were able to trace the order
+and mode in which the morbid changes
+may proceed in this disease. From any
+occasional cause, the thecal ligament, the
+membranes, or the medulla itself, may pass
+into the state of simple excitement or irritation,
+which may be gradually succeeded
+by such a local afflux and determination of
+blood into the minute vessels, as may terminate
+in actual but slow inflammation.
+The result of this would be a thickening<span class='pagenum'><a name="Page_58" id="Page_58">[58]</a></span>
+of the theca, or membranes, and perhaps an
+increase in the volume of the medulla itself,
+which would gradually occasion such
+a degree of pressure against the sides of the
+unyielding canal, as must eventually intercept
+the influence of the brain upon the
+inferior portion of the medullary column,
+and upon the parts on which the nerves of
+this portion are disposed.</p>
+
+<p>From this review, and assuming that the
+morbid changes in this disease may not be
+widely dissimilar from those which occurred
+in the case of Count de Lordat, the chance
+of relief from the proposed mode of treatment
+may appear to be sufficient to warrant
+its trial.</p>
+
+<p>In such a case then, at whatever period
+of the disease it might be proposed to attempt
+the cure, blood should be first taken
+from the upper part of the neck, unless
+contra-i(n)dicated by any particul(ar) circumstance.
+After which vesicatories should
+be applied to the (sa)me part, and a purulent
+discharge obtained by appropriate use of
+the Sabine Liniment; having recourse to<span class='pagenum'><a name="Page_59" id="Page_59">[59]</a></span>
+the application of a fresh blister, when from
+the diminution of the discharging surface,
+pus is not secreted in a sufficient quantity.
+Should the blisters be found too inconvenient,
+or a sufficient quantity of discharge not
+be obtained thereby, an issue of at least an
+inch and a half in length might be established
+on each side of the vertebral columna,
+in its superior part. These, it is
+presumed, would be best formed with caustic,
+and kept open with any proper substance<a name="FNanchor_16_17" id="FNanchor_16_17"></a><a href="#Footnote_16_17" class="fnanchor">[16]</a>.</p>
+
+<p>Could it have been imagined that such
+considerable benefit: indeed, that such
+astonishing cures, could have been effected
+by issues in cases of Palsy of the lower extremities
+from diseased spine? although satisfied
+with ascribing those cases to scrofulous
+action, we are in fact as little informed
+respecting the nature of the affection, inducing
+<span class='pagenum'><a name="Page_60" id="Page_60">[60]</a></span>the carious state of the vertebr&aelig;, as
+we are respecting the peculiar change of
+structure which takes place in this disease.
+Equally uninformed are we also as to the
+peculiar kind of morbid action, which takes
+place in the ligaments of the joints; as well
+as that which takes place in different instances
+of deep seated pains and affections
+of the parts contained in the head, thorax,
+and abdomen, and in all which cases the
+inducing of a purulent discharge in their
+neighbourhood is so frequently productive of
+a cure. Experiment has not indeed been yet
+employed to prove, but analogy certainly
+warrants the hope, that similar advantages
+might be derived from the use of the means
+enumerated, in the present disease. It is
+obvious, that the chance of obtaining relief
+will depend in a great measure on the period
+at which the means are employed. As
+in every other disease, so here, the earlier
+the remedies are resorted to, the greater will
+be the probability of success. But in this
+disease there is one circumstance which demands
+particular attention; the long period
+to which it may be extended. One of its
+peculiar symptoms, Scelotyrbe festinans,<span class='pagenum'><a name="Page_61" id="Page_61">[61]</a></span>
+may not occur until the disease has existed
+ten or twelve years, or more; hence, when
+looking for the period, within which our
+hopes of remedial aid is to be limited; we
+may, guided by the slow progress of the malady,
+extend it to a great length, when compared
+with that within which we should be
+obliged to confine ourselves in most other
+diseases.</p>
+
+<p>But it is much to be apprehended, as in
+many other cases, that the resolution of the
+patients will seldom be sufficient to enable
+them to persevere through the length of
+time which the proposed process will necessarily
+require. As slow as is the progress of
+the disease, so slow in all probability must
+be the period of the return to health. In
+most cases, especially in those in which the
+disease has been allowed to exist long unopposed,
+it may be found that all that art is
+capable of accomplishing, is that of checking
+its further progress. Nor will this be regarded
+as a trifle, when, by reference to the
+history of the disease, is seen the train of
+harassing evils which would be thus
+avoided.<span class='pagenum'><a name="Page_62" id="Page_62">[62]</a></span></p>
+
+<p>But it seems as if there existed reason for
+hoping for more. For supposing change of
+structure to have taken place, it is extremely
+probable that this change may be merely
+increase in mass or volume by interstitial addition,
+the consequence of increased action in
+the minute vessels of the part. In that case,
+should the instituting of a purulent discharge,
+in a neighbouring part, act in the manner
+which we would presume it may&mdash;should it
+by keeping up a constant discharge, not
+merely alter the determination, but diminish
+the inordinate action of the vessels in the
+diseased part; and at the same time excite
+the absorbents to such increased action as
+may remove the added matter; there will
+exist strong ground for hope, that a happy,
+though slow restoration to health, may be
+obtained.</p>
+
+<p>Until we are better informed respecting
+the nature of this disease, the employment
+of internal medicines is scarcely warrantable;
+unless analogy should point out some remedy
+the trial of which rational hope might
+authorize. Particular circumstances indeed<span class='pagenum'><a name="Page_63" id="Page_63">[63]</a></span>
+must arise in different cases, in which the
+aid of medicine may be demanded: and
+the intelligent will never fail to avail themselves
+of any opportunity of making trial of
+the influence of mercury, which has in so
+many instances, manifested its power in correcting
+derangement of structure.</p>
+
+<p>The weakened powers of the muscles in
+the affected parts is so prominent a symptom,
+as to be very liable to mislead the
+inattentive, who may regard the disease as
+a mere consequence of constitutional debility.
+If this notion be pursued, and tonic
+medicines, and highly nutritious diet be
+directed, no benefit is likely to be thus obtained;
+since the disease depends not on
+general weakness, but merely on the interruption
+of the flow of the nervous influence
+to the affected parts.</p>
+
+<p>It is indeed much to be regretted that
+this malady is generally regarded by the
+sufferers in this point of view, so discouraging
+to the employment of remedial
+means. Seldom occurring before the age of
+fifty, and frequently yielding but little inconvenience<span class='pagenum'><a name="Page_64" id="Page_64">[64]</a></span>
+for several months, it is generally
+considered as the irremediable diminution
+of the nervous influence, naturally resulting
+from declining life; and remedies
+therefore are seldom sought for.</p>
+
+<p>Although unable to trace the connection
+by which a disordered state of the stomach
+and bowels may induce a morbid action in
+a part of the medulla spinalis, yet taught
+by the instruction of Mr. Abernethy, little
+hesitation need be employed before we
+determine on the probability of such occurrence.
+The power, possessed by sympathy,
+of inducing such disordered action in
+a distant part, and the probability of such
+disordered action producing derangement
+of structure, can hardly be denied. The
+following Case seems to prove, at least,
+that the mysterious sympathetic influence
+which so closely simulates the forms of
+other diseases, may induce such symptoms
+as would seem to menace the formation of
+a disease not unlike to that which we have
+been here treating of.</p>
+
+<p><i>A.&nbsp;B.</i> A man, 54 years of age, of temperate<span class='pagenum'><a name="Page_65" id="Page_65">[65]</a></span>
+habits and regular state of bowels,
+became gradually affected with slight numbness
+and prickling, with a feeling of weakness
+in both arms, accompanied by a sense
+of fulness about the shoulders, as if produced
+by the pressure of a strong ligature;
+and at times a slight trembling of the hands.
+During the night, the fullness, numbness,
+and prickling were much increased. The
+appetite had been diminished for several
+weeks; and the abdomen, on being examined,
+felt as though containing considerable
+accumulation.</p>
+
+<p>Before adopting any other measures, and
+as there appeared to be no marks of vascular
+fulness, it was determined to empty
+the bowels. This was done effectually by
+moderate doses of calomel, with the occasional
+help of Epsom salts; and in about
+ten days, by these means alone, the complaints
+were entirely removed.</p>
+
+<p>Before concluding these pages, it may
+be proper to observe once more, that an
+important object proposed to be obtained
+by them is, the leading of the attention of<span class='pagenum'><a name="Page_66" id="Page_66">[66]</a></span>
+those who humanely employ anatomical
+examination in detecting the causes and
+nature of diseases, particularly to this malady.
+By their benevolent labours its real
+nature may be ascertained, and appropriate
+modes of relief, or even of cure, pointed
+out.</p>
+
+<p>To such researches the healing art is
+already much indebted for the enlargement
+of its powers of lessening the evils
+of suffering humanity. Little is the public
+aware of the obligations it owes to
+those who, led by professional ardour, and
+the dictates of duty, have devoted themselves
+to these pursuits, under circumstances
+most unpleasant and forbidding.
+Every person of consideration and feeling,
+may judge of the advantages yielded by
+the philanthropic exertions of a <span class="smcap">Howard</span>;
+but how few can estimate the benefits
+bestowed on mankind, by the labours of a
+<span class="smcap">Morgagni</span>, <span class="smcap">Hunter</span>, or <span class="smcap">Baillie</span>.</p>
+
+
+<p class="center" style="padding-top: 2em">FINIS.</p>
+
+<div class="footnotes"><h3>FOOTNOTES:</h3>
+
+<div class="footnote"><p><a name="Footnote_1_1" id="Footnote_1_1"></a><a href="#FNanchor_1_1"><span class="label">[1]</span></a> Synopsis Nosologi&aelig; Methodic&aelig;.&mdash;Tom. ii. p. 195.</p></div>
+
+<div class="footnote"><p><a name="Footnote_2_2" id="Footnote_2_2"></a><a href="#FNanchor_2_2"><span class="label">[2]</span></a> Junckeri conspect. de tremore.</p></div>
+
+<div class="footnote"><p><a name="Footnote_3_3" id="Footnote_3_3"></a><a href="#FNanchor_3_3"><span class="label">[3]</span></a> Sect. <small>V.</small> Ubi autem solito pauciores deferunter ad
+eadem organa spiritus animales, imperfect&aelig; ac imbecill&aelig;
+observantur fieri eadem functiones, in motu tremulo
+et infirmo, nec diu durante, in visu debili, ac mox
+defatigato, &amp;c.
+</p><p>
+Sect. <small>XIX.</small> In&aelig;qualiter, inordinat&egrave;, ac pr&aelig;ter contraque
+voluntatem moventur spiritus animales per nervos
+ad partes mobiles, in motu convulsivo, ac tremore,
+quassuve membrorum coacto.
+</p><p>
+Distinguendus namque his tremor quiescente licet ac
+decumbente corpore molustus a motu tremulo, de quo
+dictum. Sect. <small>V.</small> Quique quiescente corpore cessat,
+eodemque iterum moto repetit.
+</p><p>
+Sect. <small>XXV.</small> Coactus tremor debetur animalibus spiritibus
+inordinat&egrave; ac continuo, cum aliquo impetu ad
+trementium membrorum musculos per nervos propulsis:
+sive fuerit is universalis, sive particularis, sive corpus
+fuerit ad huc robustum sive debile, Sylvii de la Boe.
+Prax. lib. i. cap. xlii.</p></div>
+
+<div class="footnote"><p><a name="Footnote_4_4" id="Footnote_4_4"></a><a href="#FNanchor_4_4"><span class="label">[4]</span></a> Nosolog. Methodic. Auctore Fr. Boissier de Sauvages,
+Tomi. II. Partis ii. p. 54. 1763.</p></div>
+
+<div class="footnote"><p><a name="Footnote_5_5" id="Footnote_5_5"></a><a href="#FNanchor_5_5"><span class="label">[5]</span></a> Comment, in Herman. Boerhaav. Aphorismos. Tom.
+ii. p. 181.</p></div>
+
+<div class="footnote"><p><a name="Footnote_6_6" id="Footnote_6_6"></a><a href="#FNanchor_6_6"><span class="label">[6]</span></a> De tremore. Cap. 3 and 4. Chart, Tom. vii. p.
+200-201.</p></div>
+
+<div class="footnote"><p><a name="Footnote_7_7" id="Footnote_7_7"></a><a href="#FNanchor_7_7"><span class="label">[7]</span></a> Sect. <small>XVI.</small> <i>Tremor palpitans</i>, Preysinger classis
+morborum. <i>Palmos</i> Galeni.
+</p><p>
+In tremoribus vulgaribus, &aelig;qualibus temporum intervallis,
+non musculus, sed artus ipsemet alternatim attollitur
+aut deprimitur, aut in oppositas partes it atque
+redit per minima tamen spatiola; in palpitatione ver&ograve;
+sine ullo ordine musculi unius lacertus subito subsilit,
+nec regulariter continuoque movetur, sed nunc semel aut
+bis, nunc minim&eacute; intra idem tempus subsilit; an causa
+irritans in sensorio communi, an in musculo ipse palpitante
+Qu&aelig;renda sit, ignoramus. <i>Nosologi&aelig; Methodic&aelig;</i>,
+Vol. I. p. 559. 1768.
+</p><p>
+But the adoption which Sauvages has made of this
+term, will not be regarded as an absolute prohibition
+from the employment of it here; since the <i>tremor palpitans</i>
+of Sauvages should be considered rather as a palpitation
+of the muscles, whilst the motion which is so
+prominent a symptom in this disease, may be considered
+as a palpitation of the limbs.</p></div>
+
+<div class="footnote"><p><a name="Footnote_8_8" id="Footnote_8_8"></a><a href="#FNanchor_8_8"><span class="label">[8]</span></a> Est et ubi musculi, recte quidem ad voluntatis
+nutum in actum concitati, injussa dein agilitate atque
+impetu non reprimendo motus suos accelerant, mentemque
+invitam pr&aelig;currunt. Vitium loquel&aelig; musculis
+frequens, nec his solis tamen proprium: vidi enim, qui
+currere, non gradi, poterat<a name="FNanchor_A_9" id="FNanchor_A_9"></a><a href="#Footnote_A_9" class="fnanchor">[A]</a>.</p></div>
+
+<div class="footnote"><p style="padding-left: 4em"><a name="Footnote_A_9" id="Footnote_A_9"></a><a href="#FNanchor_A_9"><span class="label2">[A]</span></a> Institution, Patholog. Medicinal. Auctore. H.&nbsp;D. Gaubio. 751.</p></div>
+
+<div class="footnote"><p><a name="Footnote_9_10" id="Footnote_9_10"></a><a href="#FNanchor_9_10"><span class="label">[9]</span></a> Ad idem genus morbi altera species rarissima ab auctoribus
+pr&aelig;tervisa referenda videtur, quam non aptius
+nominari posse putem qu&agrave;m scelotyrbem festinantem,
+seu festiniam.
+</p><p>
+<span class="smcap">Sect. II.</span> <i>Scelotyrbe festinans</i>: est peculiaris scelotyrbes
+species in qua &aelig;gri solito more dum gradi volunt
+currere coguntur, quod videre est apud D. Carquet, et
+observavit Leyd&aelig; illustr. Gaubius. <i>Patholog. instit.</i> 751,
+et in loquela h&aelig;c <i>volubilitas</i> dicitur qu&acirc; lingua pr&aelig;currit
+mentem. Video actu mulierem sexagenariam hoc
+affectam morbo siccitati nervorum tribuendo; laborat
+enim rheumatismo sicco, seu ab acrimonia sanguinis,
+dolores nocte a calore recrudescunt, &agrave; thermis non sublevantur:
+ei pr&aelig;scripsi phlebotomiam, et pr&aelig;missis jusculis
+ex lactuc&acirc;, endivi&acirc;, et collo arietis, lene catharticum,
+inde vero lacticinia.
+</p><p>
+Est affinitas cum scelotyrbe, chorea viti, deest flexibilitas
+in fibris musculorum; unde motus breves edunt,
+et conatu seu impetu solito majori, cum resistentiam
+illam superare nituntur, velut inviti festinant, ac pr&aelig;cipiti
+seu concitato passu gradiuntur. Chorea viti pueros,
+puellasve impuberes aggreditur; festinia vero senes,
+et duos tantum hactenus observare mihi contigit. Quam
+multos autem videmus morbos, paucissimosque observamus.
+De theoria et pr&agrave;xi nihil habeo quod dicam;
+etenim sola experienta praxin cujusvis morbi determinat,
+et ex hac pro felici vel infausto successu theoria
+dein elicienda est. <i>Nosolog. Methodic.</i> Auctore, Fr.
+Boissier de Sauvages. Tomi. II. Part ii. p. 108.</p></div>
+
+<div class="footnote"><p><a name="Footnote_10_11" id="Footnote_10_11"></a><a href="#FNanchor_10_11"><span class="label">[10]</span></a> Corporis agitatio continua, indolens, convulsiva, cum
+sensibilitate.&mdash;<i>Linn.</i>
+</p><p>
+Agitatio corporis vel artuum convulsiva continua,
+chronica, cum integritate sensuum.&mdash;<i>Vogel.</i>
+</p><p>
+This genus is resolved by Cullen into that of Convulsio.
+<i>Synops. Nosol.</i> 1803.
+</p><p>
+Dr. Macbride has given a very interesting and illustrative
+case of this disease.
+</p><p>
+&#8220;Hieranasos, or Morbus Sacer, so called, as being vulgarly
+supposed to arise from witchcraft, or some extraordinary
+celestial influence, is a distinct genus of disease,
+though a very uncommon one; the author once had
+an opportunity of seeing a case. The patient was a lad
+about seventeen, who at that time had laboured under
+this extraordinary disease for more than twelve years.
+His body was so distorted, and the legs and arms so
+twisted round it, by the continued convulsive working,
+that no words can give an adequate idea of the oddity
+of his figure; the agitation of the muscles was perpetual;
+but in general he did not complain of pain nor
+sickness; and had his senses perfectly, insomuch that
+he used to assist his mother, who kept a little school,
+in teaching children to read.&#8221; <i>A methodical Introduction
+to the Theory and Practice of Physic. By David Macbride,
+M.D. p. 559.</i></p></div>
+
+<div class="footnote"><p><a name="Footnote_11_12" id="Footnote_11_12"></a><a href="#FNanchor_11_12"><span class="label">[11]</span></a> Medical Observations and Inquiries, Vol. III. p. 257.</p></div>
+
+<div class="footnote"><p><a name="Footnote_12_13" id="Footnote_12_13"></a><a href="#FNanchor_12_13"><span class="label">[12]</span></a> A coagulum of blood, the thickness of a crown-piece,
+was found lying upon the external surface of
+the dura-matral covering of the medulla spinalis, extending
+from the fourth vertebra colli to the second
+vertebra dorsi. The medulla spinalis itself was uninjured.</p></div>
+
+<div class="footnote"><p><a name="Footnote_13_14" id="Footnote_13_14"></a><a href="#FNanchor_13_14"><span class="label">[13]</span></a> The sixth and seventh vertebra colli were dislocated,
+the medulla spinalis, externally, was uninjured;
+but in the centre of its substance, just at that part,
+there was a coagulum of blood nearly two inches in
+length.</p></div>
+
+<div class="footnote"><p><a name="Footnote_14_15" id="Footnote_14_15"></a><a href="#FNanchor_14_15"><span class="label">[14]</span></a> The seventh vertebra colli was fractured, and the
+medulla spinalis passing through it, was lacerated and
+compressed.</p></div>
+
+<div class="footnote"><p><a name="Footnote_15_16" id="Footnote_15_16"></a><a href="#FNanchor_15_16"><span class="label">[15]</span></a> The spinal marrow, within the canal of the sixth
+vertebra dorsi, was completely destroyed by a musket
+ball. The person lived four days.</p></div>
+
+<div class="footnote"><p><a name="Footnote_16_17" id="Footnote_16_17"></a><a href="#FNanchor_16_17"><span class="label">[16]</span></a> Cork, which has been hitherto neglected, appears
+to be very appropriate to this purpose. It possesses
+lightness, softness, elasticity and sufficient firmness; and
+is also capable of being readily fashioned to any convenient
+form. The form which it seems would be best
+adapted to the part, is that of an almond, or of the variety
+of bean called scarlet bean; but at least an inch
+and a half in length.</p></div>
+</div>
+
+
+
+
+
+
+
+<pre>
+
+
+
+
+
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+Project Gutenberg's An Essay on the Shaking Palsy, by James Parkinson
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+
+Title: An Essay on the Shaking Palsy
+
+Author: James Parkinson
+
+Release Date: December 9, 2007 [EBook #23777]
+
+Language: English
+
+Character set encoding: ASCII
+
+*** START OF THIS PROJECT GUTENBERG EBOOK AN ESSAY ON THE SHAKING PALSY ***
+
+
+
+
+Produced by Irma Spehar and the Online Distributed
+Proofreading Team at http://www.pgdp.net
+
+
+
+
+
+                    AN ESSAY ON THE SHAKING PALSY.
+
+                                  BY
+
+                          _JAMES PARKINSON,_
+
+               MEMBER OF THE ROYAL COLLEGE OF SURGEONS.
+
+                               _LONDON:_
+
+                  PRINTED BY WHITTINGHAM AND ROWLAND,
+
+                           _Goswell Street,_
+
+                    FOR SHERWOOD, NEELY, AND JONES,
+
+                           PATERNOSTER ROW.
+
+                                 1817.
+
+
+
+
+                               PREFACE.
+
+
+The advantages which have been derived from the caution with which
+hypothetical statements are admitted, are in no instance more obvious
+than in those sciences which more particularly belong to the healing
+art. It therefore is necessary, that some conciliatory explanation
+should be offered for the present publication: in which, it is
+acknowledged, that mere conjecture takes the place of experiment; and,
+that analogy is the substitute for anatomical examination, the only
+sure foundation for pathological knowledge.
+
+When, however, the nature of the subject, and the circumstances under
+which it has been here taken up, are considered, it is hoped that the
+offering of the following pages to the attention of the medical
+public, will not be severely censured. The disease, respecting which
+the present inquiry is made, is of a nature highly afflictive.
+Notwithstanding which, it has not yet obtained a place in the
+classification of nosologists; some have regarded its characteristic
+symptoms as distinct and different diseases, and others have given its
+name to diseases differing essentially from it; whilst the unhappy
+sufferer has considered it as an evil, from the domination of which he
+had no prospect of escape.
+
+The disease is of long duration: 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.
+Of both these advantages the writer has had the opportunities of
+availing himself; and has hence been led particularly to observe
+several other cases in which the disease existed in different stages
+of its progress. By these repeated observations, he hoped that he had
+been led to a probable conjecture as to the nature of the malady, and
+that analogy had suggested such means as might be productive of
+relief, and perhaps even of cure, if employed before the disease had
+been too long established. He therefore considered it to be a duty to
+submit his opinions to the examination of others, even in their
+present state of immaturity and imperfection.
+
+To delay their publication did not, indeed, appear to be warrantable.
+The disease had escaped particular notice; and the task of
+ascertaining its nature and cause by anatomical investigation, did not
+seem likely to be taken up by those who, from their abilities and
+opportunities, were most likely to accomplish it. That these friends
+to humanity and medical science, who have already unveiled to us many
+of the morbid processes by which health and life is abridged, might be
+excited to extend their researches to this malady, was much desired;
+and it was hoped, that this might be procured by the publication of
+these remarks.
+
+Should the necessary information be thus obtained, the writer will
+repine at no censure which the precipitate publication of mere
+conjectural suggestions may incur; but shall think himself fully
+rewarded by having excited the attention of those, who may point out
+the most appropriate means of relieving a tedious and most distressing
+malady.
+
+
+
+
+                               CONTENTS.
+
+
+        CHAP. I.
+                                                             PAGE
+DEFINITION--HISTORY--ILLUSTRATIVE CASES                        1
+
+        CHAP. II.
+
+PATHOGNOMONIC SYMPTOMS EXAMINED--TREMOR
+COACTUS--SCELOTYRBE FESTINANS                                 19
+
+        CHAP. III.
+
+SHAKING PALSY DISTINGUISHED FROM OTHER DISEASES
+WITH WHICH IT MAY BE CONFOUNDED                               27
+
+        CHAP. IV.
+
+PROXIMATE CAUSE--REMOTE CAUSES--ILLUSTRATIVE
+CASES                                                         33
+
+        CHAP. V.
+
+CONSIDERATIONS RESPECTING THE MEANS OF CURE                   56
+
+
+
+
+                    AN ESSAY ON THE SHAKING PALSY.
+
+
+
+
+                              CHAPTER I.
+
+               DEFINITION--HISTORY--ILLUSTRATIVE CASES.
+
+
+                 SHAKING PALSY. (_Paralysis Agitans._)
+
+     Involuntary tremulous motion, with lessened muscular 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.
+
+The term Shaking Palsy has been vaguely employed by medical writers in
+general. By some it has been used to designate ordinary cases of
+Palsy, in which some slight tremblings have occurred; whilst by others
+it has been applied to certain anomalous affections, not belonging to
+Palsy.
+
+The shaking of the limbs belonging to this disease was particularly
+noticed, as will be seen when treating of the symptoms, by Galen, who
+marked its peculiar character by an appropriate term. The same
+symptom, it will also be seen, was accurately treated of by Sylvius de
+la Boe. Juncker also seems to have referred to this symptom: having
+divided tremor into active and passive, he says of the latter, "ad
+affectus semiparalyticos pertinent; de qualibus hic agimus, quique
+_tremores paralytoidei_ vocantur." Tremor has been adopted, as a
+genus, by almost every nosologist; but always unmarked, in their
+several definitions, by such characters as would embrace this disease.
+The celebrated Cullen, with his accustomed accuracy observes,
+"Tremorem, utpote semper symptomaticum, in numerum generum recipere
+nollem; species autem a Sauvagesio recensitas, prout mihi vel astheniae
+vel paralysios, vel convulsionis symptomata esse videntur, his
+subjungam[1]." Tremor can indeed only be considered as a symptom,
+although several species of it must be admitted. In the present
+instance, the agitation produced by the peculiar species of tremor,
+which here occurs, is chosen to furnish the epithet by which this
+species of Palsy, may be distinguished.
+
+    [Footnote 1: Synopsis Nosologiae Methodicae.--Tom. ii. p. 195.]
+
+
+                               HISTORY.
+
+So slight and nearly imperceptible are the first inroads of this
+malady, and so extremely slow is its progress, that it rarely happens,
+that the patient can form any recollection of the precise period of
+its commencement. The first symptoms perceived 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.
+These symptoms gradually increase in the part first affected; and at
+an uncertain period, but seldom in less than twelvemonths or more, the
+morbid influence is felt in some other part. Thus assuming one of the
+hands and arms to be first attacked, the other, at this period
+becomes similarly affected. After a few more months the patient is
+found to be less strict than usual in preserving an upright posture:
+this being most observable whilst walking, but sometimes whilst
+sitting or standing. Sometime after the appearance of this symptom,
+and during its slow increase, one of the legs is discovered slightly
+to tremble, and is also found to suffer fatigue sooner than the leg of
+the other side: and in a few months this limb becomes agitated by
+similar tremblings, and suffers a similar loss of power.
+
+Hitherto the patient will have experienced but little inconvenience;
+and befriended by the strong influence of habitual endurance, would
+perhaps seldom think of his being the subject of disease, except when
+reminded of it by the unsteadiness of his hand, whilst writing or
+employing himself in any nicer kind of manipulation. But as the
+disease proceeds, similar employments are accomplished with
+considerable difficulty, the hand failing to answer with exactness to
+the dictates of the will. Walking becomes a task which cannot be
+performed without considerable attention. The legs are not raised to
+that height, or with that promptitude which the will directs, so that
+the utmost care is necessary to prevent frequent falls.
+
+At this period the patient experiences much inconvenience, which
+unhappily is found daily to increase. The submission of the limbs to
+the directions of the will can hardly ever be obtained in the
+performance of the most ordinary offices of life. The fingers cannot
+be disposed of in the proposed directions, and applied with certainty
+to any proposed point. As time and the disease proceed, difficulties
+increase: writing can now be hardly at all accomplished; and reading,
+from the tremulous motion, is accomplished with some difficulty.
+Whilst at meals the fork not being duly directed frequently fails to
+raise the morsel from the plate: which, when seized, is with much
+difficulty conveyed to the mouth. At this period the patient seldom
+experiences a suspension of the agitation of his limbs. Commencing,
+for instance in one arm, the wearisome agitation is borne until
+beyond sufferance, when by suddenly changing the posture it is for a
+time stopped in that limb, to commence, generally, in less than a
+minute in one of the legs, or in the arm of the other side. Harassed
+by this tormenting round, the patient has recourse to walking, a mode
+of exercise to which the sufferers from this malady are in general
+partial; owing to their attention being thereby somewhat diverted from
+their unpleasant feelings, by the care and exertion required to ensure
+its safe performance.
+
+But as the malady proceeds, even this temporary mitigation of
+suffering from the agitation of the limbs is denied. 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, when this state of the malady is
+attained, the patient can no longer exercise himself by walking in his
+usual manner, but is thrown on the toes and forepart of the feet;
+being, at the same time, irresistibly impelled to take much quicker
+and shorter steps, and thereby to adopt unwillingly a running pace. In
+some cases it is found necessary entirely to substitute running for
+walking; since otherwise the patient, on proceeding only a very few
+paces, would inevitably fall.
+
+In this stage, the sleep becomes much disturbed. The tremulous motion
+of the limbs occur during sleep, and augment until they awaken the
+patient, and frequently with much agitation and alarm. 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 of
+very considerable power: the expulsion of the faeces from the rectum
+sometimes requiring mechanical aid. As the disease proceeds towards
+its last stage, the trunk is almost permanently bowed, the muscular
+power is more decidedly diminished, and the tremulous agitation
+becomes violent. The patient walks now with great difficulty, and
+unable any longer to support himself with his stick, he dares not
+venture on this 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. His words are now
+scarcely intelligible; and 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, pharynx, &c. impeded by impaired
+action and perpetual agitation, that the food is with difficulty
+retained in the mouth until masticated; and then as difficultly
+swallowed. Now also, from the same cause, another very unpleasant
+circumstance occurs: the saliva fails of being directed to the back
+part of the fauces, and hence is continually draining from the mouth,
+mixed with the particles of food, which he is no longer able to clear
+from the inside of the mouth.
+
+As the debility increases and the influence of the will over the
+muscles fades away, the tremulous agitation becomes more vehement. It
+now seldom leaves him for a moment; but even when exhausted nature
+seizes a small portion of sleep, the motion becomes so violent as not
+only to shake the bed-hangings, but even the floor and sashes of the
+room. The chin is now almost immoveably 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. The urine and faeces are passed involuntarily; and at the last,
+constant sleepiness, with slight delirium, and other marks of extreme
+exhaustion, announce the wished-for release.
+
+
+                                CASE I.
+
+Almost every circumstance noted in the preceding description, was
+observed in a case which occurred several years back, and which, from
+the particular 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;
+excited an eager wish to acquire some further knowledge of its nature
+and cause.
+
+The subject of this case was a man rather more than fifty years of
+age, who had industriously followed the business of a gardener,
+leading a life of remarkable temperance and sobriety. The commencement
+of the malady was first manifested by a slight trembling of the left
+hand and arm, a circumstance which he was disposed to attribute to his
+having been engaged for several days in a kind of employment requiring
+considerable exertion of that limb. Although repeatedly questioned, he
+could recollect no other circumstance which he could consider as
+having been likely to have occasioned his malady. He had not suffered
+much from Rheumatism, or been subject to pains of the head, or had
+ever experienced any sudden seizure which could be referred to
+apoplexy or hemiplegia. In this case, every circumstance occurred
+which has been mentioned in the preceding history.
+
+
+                               CASE II.
+
+The subject of the case which was next noticed was casually met with
+in the street. It was a man sixty-two years of age; the greater part
+of whose life had been spent as an attendant at a magistrate's office.
+He had suffered from the disease about eight or ten years. All the
+extremities were considerably agitated, the speech was very much
+interrupted, and the body much bowed and shaken. He 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. He described the
+disease as having come on very gradually, and as being, according to
+his full assurance, the consequence of considerable irregularities in
+his mode of living, and particularly of indulgence in spirituous
+liquors. He was the inmate of a poor-house of a distant parish, and
+being fully assured of the incurable nature of his complaint, declined
+making any attempts for relief.
+
+
+                               CASE III.
+
+The next case was also noticed casually in the street. The subject of
+it was a man of about sixty-five years of age, of a remarkable
+athletic frame. The agitation of the limbs, and indeed of the head and
+of the whole body, was too vehement to allow it to be designated as
+trembling. 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. He stated, that he had been a sailor, and
+attributed his complaints to having been for several months confined
+in a Spanish prison, where he had, during the whole period of his
+confinement, lain upon the bare damp earth. The disease had here
+continued so long, and made such a progress, as to afford little or no
+prospect of relief. He besides was a poor mendicant, requiring as well
+as the means of medical experiment, those collateral aids which he
+could only obtain in an hospital. He was therefore recommended to make
+trial if any relief could, in that mode, be yielded him. The poor man,
+however, appeared to be by no means disposed to make the experiment.
+
+
+                               CASE IV.
+
+The next case which presented itself was that of a gentleman about
+fifty-five years, who had first experienced the trembling of the arms
+about five years before. His application was on account of a
+considerable degree of inflammation over the lower ribs on the left
+side, which terminated in the formation of matter beneath the fascia.
+About a pint was removed on making the necessary opening; and a
+considerable quantity discharged daily for two or three weeks. On his
+recovery from this, no change appeared to have taken place in his
+original complaint; and the opportunity of learning its future
+progress was lost by his removal to a distant part of the country.
+
+
+                                CASE V.
+
+In another case, the particulars of which could not be obtained, and
+the gentleman, the lamented subject of which was only seen at a
+distance, one of the characteristic symptoms of this malady, the
+inability for motion, except in a running pace, appeared to exist in
+an extraordinary degree. It seemed to be necessary that the gentleman
+should be supported by his attendant, 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, after his having run about twenty paces.
+
+
+                               CASE VI.
+
+In a case which presented itself to observation since those
+above-mentioned, every information as to the progress of the malady
+was very readily obtained. The gentleman who was the subject of it is
+seventy-two years of age. He has led a life of temperance, and has
+never been exposed to any particular situation or circumstance which
+he can conceive likely to have occasioned, or disposed to this
+complaint; which he rather seems to regard as incidental upon his
+advanced age, than as an object of medical attention. He however
+recollects, that about twenty years ago, he was troubled with
+lumbago, which was severe and lasted some time. About eleven or
+twelve, or perhaps more, years ago, he first perceived weakness in the
+left hand and arm, and soon after found the trembling commence. In
+about three years afterwards the right arm became affected in a
+similar manner: and soon afterwards the convulsive motions affected
+the whole body, and began to interrupt the speech. In about three
+years from that time the legs became affected. Of late years the
+action of the bowels had been very much retarded; and at two or three
+different periods had, with great difficulty, been made to yield to
+the action of very strong cathartics. But within the last twelvemonths
+this difficulty has not been so great; perhaps owing to an increased
+secretion of mucus, which envelopes the passing faeces, and which
+precedes and follows their discharge in considerable quantity.
+
+About a year since, on waking in the night, he found that he had
+nearly lost the use of the right side, and that the face was much
+drawn to the left side. His medical attendant saw him the following
+day, when he found him languid, with a small and quick pulse, and
+without pain in the head or disposition to sleep. Nothing more
+therefore was done than to promote the action of the bowels, and apply
+a blister to the back of the neck, and in about a fortnight the limbs
+had entirely recovered from their palsied state. During the time of
+their having remained in this state, neither the arm nor the leg of
+the paralytic side was in the least affected with the tremulous
+agitation; but as their paralysed state was removed, the shaking
+returned.
+
+At present he is almost constantly troubled with the agitation, which
+he describes as generally commencing in a slight degree, and gradually
+increasing, until it arises to such a height as to shake the room;
+when, by a sudden and somewhat violent change of posture, he is almost
+always able to stop it. But very soon afterwards it will commence in
+some other limb, in a small degree, and gradually increase in
+violence; but he does not remember the thus checking of it, to have
+been followed by any injurious effect. When the agitation had not
+been thus interrupted, he stated, that it gradually extended through
+all the limbs, and at last affected the whole trunk. To illustrate his
+observation as to the power of suspending the motion by a sudden
+change of posture, 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' time.
+
+He now possessed but little power in giving a required direction to
+the motions of any part. He was scarcely able to feed himself. He had
+written hardly intelligibly for the last three years; and at present
+could not write at all. His attendants observed, that of late the
+trembling would sometimes begin in his sleep, and increase until it
+awakened him: when he always was in a state of agitation and alarm.
+
+On 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.
+
+The preceding 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.
+
+
+
+
+                               CHAP. II.
+
+    PATHOGNOMONIC SYMPTOMS EXAMINED--_TREMOR COACTUS_--_SCELOTYRBE
+                              FESTINANS_.
+
+
+It has been seen in the preceding history of the disease, and in the
+accompanying cases, that certain affections, the tremulous agitations,
+and the almost invincible propensity to run, when wishing only to
+walk, each of which has been considered by nosologists as distinct
+diseases, appear to be pathognomonic symptoms of this malady. To
+determine in which of these points of view these affections ought to
+be regarded, an examination into their nature, and an inquiry into the
+opinions of preceding writers respecting them, seem necessary to be
+attempted.
+
+       *       *       *       *       *
+
+I. _Involuntary tremulous motion, with lessened voluntary muscular
+power, in parts, not in action, and even supported._
+
+It is necessary that the peculiar nature of this tremulous motion
+should be ascertained, as well for the sake of giving to it its
+proper designation, as for assisting in forming probable conjectures,
+as to the nature of the malady, which it helps to characterise.
+Tremors were distinguished by Juncker into Active, those proceeding
+from sudden affection of the minds, as terror, anger, &c. and Passive,
+dependant on debilitating causes, such as advanced age, palsy, &c[2].
+But a much more satisfactory and useful distinction is made by Sylvius
+de la Boe into those tremors which are produced by attempts at
+voluntary motion, and those which occur whilst the body is at rest[3].
+Sauvages distinguishes the latter of these species (_Tremor Coactus_)
+by observing, that the tremulous parts leap, and as it were vibrate,
+even when supported: whilst every other tremor, he observes, ceases,
+when the voluntary exertion for moving the limb stops, or the part is
+supported, but returns when we will the limb to move; whence, he says,
+tremor is distinguished from every other kind of spasm[4].
+
+    [Footnote 2: Junckeri conspect. de tremore.]
+
+    [Footnote 3: Sect. V. Ubi autem solito pauciores deferunter
+    ad eadem organa spiritus animales, imperfectae ac imbecillae
+    observantur fieri eadem functiones, in motu tremulo et
+    infirmo, nec diu durante, in visu debili, ac mox defatigato,
+    &c.
+
+    Sect. XIX. Inaequaliter, inordinate, ac praeter contraque
+    voluntatem moventur spiritus animales per nervos ad partes
+    mobiles, in motu convulsivo, ac tremore, quassuve membrorum
+    coacto.
+
+    Distinguendus namque his tremor quiescente licet ac
+    decumbente corpore molustus a motu tremulo, de quo dictum.
+    Sect. V. Quique quiescente corpore cessat, eodemque iterum
+    moto repetit.
+
+    Sect. XXV. Coactus tremor debetur animalibus spiritibus
+    inordinate ac continuo, cum aliquo impetu ad trementium
+    membrorum musculos per nervos propulsis: sive fuerit is
+    universalis, sive particularis, sive corpus fuerit ad huc
+    robustum sive debile, Sylvii de la Boe. Prax. lib. i. cap.
+    xlii.]
+
+    [Footnote 4: Nosolog. Methodic. Auctore Fr. Boissier de
+    Sauvages, Tomi. II. Partis ii. p. 54. 1763.]
+
+A small degree of attention will be sufficient to perceive, that
+Sauvages, by this just distinction, actually separates this kind of
+tremulous motion, and which is the kind peculiar to this disease, from
+the Genus Tremor. In doing this he is fully warranted by the
+observations of Galen on the same subject, as noticed by Van
+Swieten[5]. "Binas has tremoris species[6] Galenus subtiliter
+distinxit, atque etiam diversis nominibus insignivit, tremor enim
+([Greek: trom &]) facultatis corpus moventis et vehentis infirmitate
+oboritur. Quippe nemo, qui artus movere non instituerit tremet.
+Palpitantes autem partes, etiam in quiete fuerint, etiamsi nullum
+illis motum induxeris palpitant. Ideo primam (_posteriorem_) modo
+descriptam tremoris speciem, quando quiescenti homini involuntariis
+illis et alternis motibus agitantur membra, palpitationem ([Greek:
+palmon]) dixit, posteriorem (_primam_) vero, quae non fit nisi homo
+conetur partes quasdam movere tremorem vocavit."
+
+    [Footnote 5: Comment, in Herman. Boerhaav. Aphorismos. Tom.
+    ii. p. 181.]
+
+    [Footnote 6: De tremore. Cap. 3 and 4. Chart, Tom. vii. p.
+    200-201.]
+
+Under this authority the term palpitation may be employed to mark
+those morbid motions which chiefly characterise this disease,
+notwithstanding that this term has been anticipated by Sauvages, as
+characteristic of another species of tremor[7]. The separation of
+palpitation of the limbs (_Palmos_ of Galen, _Tremor Coactus_ of de la
+Boe) from tremor, is the more necessary to be insisted on, since the
+distinction may assist in leading to a knowledge of the seat of the
+disease. It is also necessary to bear in mind, that this affection is
+distinguishable from tremor, by the agitation, in the former,
+occurring whilst the affected part is supported and unemployed, and
+being even checked by the adoption of voluntary motion; whilst in the
+latter, the tremor is induced immediately on bringing the parts into
+action. Thus an artist, afflicted with the malady here treated of,
+whilst his hand and arm is palpitating strongly, will seize his
+pencil, and the motions will be suspended, allowing him to use it for
+a short period; but in tremor, if the hand be quite free from the
+affection, should the pen or pencil be taken up, the trembling
+immediately commences.
+
+    [Footnote 7: Sect. XVI. _Tremor palpitans_, Preysinger
+    classis morborum. _Palmos_ Galeni.
+
+    In tremoribus vulgaribus, aequalibus temporum intervallis, non
+    musculus, sed artus ipsemet alternatim attollitur aut
+    deprimitur, aut in oppositas partes it atque redit per minima
+    tamen spatiola; in palpitatione vero sine ullo ordine musculi
+    unius lacertus subito subsilit, nec regulariter continuoque
+    movetur, sed nunc semel aut bis, nunc minime intra idem
+    tempus subsilit; an causa irritans in sensorio communi, an in
+    musculo ipse palpitante Quaerenda sit, ignoramus. _Nosologiae
+    Methodicae_, Vol. I. p. 559. 1768.
+
+    But the adoption which Sauvages has made of this term, will
+    not be regarded as an absolute prohibition from the
+    employment of it here; since the _tremor palpitans_ of
+    Sauvages should be considered rather as a palpitation of the
+    muscles, whilst the motion which is so prominent a symptom in
+    this disease, may be considered as a palpitation of the
+    limbs.]
+
+       *       *       *       *       *
+
+II. _A propensity to bend the trunk forwards, and to pass from a
+walking to a running pace._
+
+This affection, which observation seems to authorise the being
+considered as a symptom peculiar to this disease, has been mentioned
+by few nosologists: it appears to have been first noticed by Gaubius,
+who says, "Cases occur in which the muscles duly excited into action
+by the impulse of the will, do then, with an unbidden agility, and
+with an impetus not to be repressed, accelerate their motion, and run
+before the unwilling mind. It is a frequent fault of the muscles
+belonging to speech, nor yet of these alone: I have seen one, who was
+able to run, but not to walk[8]."
+
+    [Footnote 8: Est et ubi musculi, recte quidem ad voluntatis
+    nutum in actum concitati, injussa dein agilitate atque impetu
+    non reprimendo motus suos accelerant, mentemque invitam
+    praecurrunt. Vitium loquelae musculis frequens, nec his solis
+    tamen proprium: vidi enim, qui currere, non gradi,
+    poterat[A].]
+
+        [Footnote A: Institution, Patholog. Medicinal. Auctore. H. D.
+        Gaubio. 751.]
+
+Sauvages, referring to this symptom, says, another disease which has
+been very rarely seen by authors, appears to be referable to the same
+genus (Scelotyrbe, of which he makes _Chorea sancti viti_ the first
+species); which, he says, "I think cannot be more fitly named than
+hastening or hurrying Scelotyrbe (_Scelotyrbem festinantem, seu
+festiniam_)."
+
+_Scelotyrbe festinans_, he says, is a peculiar species of scelotyrbe,
+in which the patients, whilst wishing to walk in the ordinary mode,
+are forced to run, which has been seen by Carguet and by the
+illustrious Gaubius; a similar affection of the speech, when the
+tongue thus outruns the mind, is termed volubility. Mons. de Sauvages
+attributes this complaint to a want of flexibility in the muscular
+fibres. Hence, he supposes, that the patients make shorter steps, and
+strive with a more than common exertion or impetus to overcome the
+resistance; walking with a quick and hastened step, as if hurried
+along against their will. _Chorea Viti_, he says, attacks the youth
+of both sexes, but this disease only those advanced in years; and
+adds, that it has hitherto happened to him to have seen only two of
+these cases; and that he has nothing to offer respecting them, either
+in theory or practice[9].
+
+    [Footnote 9: Ad idem genus morbi altera species rarissima ab
+    auctoribus praetervisa referenda videtur, quam non aptius
+    nominari posse putem quam scelotyrbem festinantem, seu
+    festiniam.
+
+    SECT. II. _Scelotyrbe festinans_: est peculiaris scelotyrbes
+    species in qua aegri solito more dum gradi volunt currere
+    coguntur, quod videre est apud D. Carquet, et observavit
+    Leydae illustr. Gaubius. _Patholog. instit._ 751, et in
+    loquela haec _volubilitas_ dicitur qua lingua praecurrit
+    mentem. Video actu mulierem sexagenariam hoc affectam morbo
+    siccitati nervorum tribuendo; laborat enim rheumatismo sicco,
+    seu ab acrimonia sanguinis, dolores nocte a calore
+    recrudescunt, a thermis non sublevantur: ei praescripsi
+    phlebotomiam, et praemissis jusculis ex lactuca, endivia, et
+    collo arietis, lene catharticum, inde vero lacticinia.
+
+    Est affinitas cum scelotyrbe, chorea viti, deest flexibilitas
+    in fibris musculorum; unde motus breves edunt, et conatu seu
+    impetu solito majori, cum resistentiam illam superare
+    nituntur, velut inviti festinant, ac praecipiti seu concitato
+    passu gradiuntur. Chorea viti pueros, puellasve impuberes
+    aggreditur; festinia vero senes, et duos tantum hactenus
+    observare mihi contigit. Quam multos autem videmus morbos,
+    paucissimosque observamus. De theoria et praxi nihil habeo
+    quod dicam; etenim sola experienta praxin cujusvis morbi
+    determinat, et ex hac pro felici vel infausto successu
+    theoria dein elicienda est. _Nosolog. Methodic._ Auctore, Fr.
+    Boissier de Sauvages. Tomi. II. Part ii. p. 108.]
+
+Having made the necessary inquiries respecting these two affections,
+_Tremor coactum_ of Sylvius de la Boe and of Sauvages, and _Scelotyrbe
+festinans_ of the latter nosologist, which appear to be characteristic
+symptoms of this disease, it becomes necessary, in the next place, to
+endeavour to distinguish this disease from others which may bear a
+resemblance to it in some particular respects.
+
+
+
+
+                              CHAP. III.
+
+ SHAKING PALSY DISTINGUISHED FROM OTHER DISEASES WITH WHICH IT MAY BE
+                              CONFOUNDED.
+
+
+Treating of a disease resulting from an assemblage of symptoms, some
+of which do not appear to have yet engaged the general notice of the
+profession, particular care is required whilst endeavouring to mark
+its diagnostic characters. It is sufficient, in general, to point out
+the characteristic differences which are observable between diseases
+in some respects resembling each other. But in this case more is
+required: it is necessary to show that it is a disease which does not
+accord with any which are marked in the systematic arrangements of
+nosologists; and that the name by which it is here distinguished has
+been hitherto vaguely applied to diseases very different from each
+other, as well as from that to which it is now appropriated.
+
+Palsy, either consequent to compression of the brain, or dependent on
+partial exhaustion of the energy of that organ, may, when the palsied
+limbs become affected with tremulous motions, be confounded with this
+disease. In those cases the abolition or diminution of voluntary
+muscular action takes place suddenly, the sense of feeling being
+sometimes also impaired. But in this disease, the diminution of the
+influence of the will on the muscles comes on with extreme slowness,
+is always accompanied, and even preceded, by agitations of the
+affected parts, and never by a lessened sense of feeling. The dictates
+of the will are even, in the last stages of the disease, conveyed to
+the muscles; and the muscles act on this impulse, but their actions
+are perverted.
+
+Anomalous cases of convulsive affections have been designated by the
+term Shaking Palsy: a term which appears to be improperly applied to
+these cases, independent of the want of accordance between them and
+that disease which has been here denominated Shaking Palsy. Dr.
+Kirkland, in his commentary on Apoplectic and Paralytic Affections,
+&c. cites the following case, related by Dr. Charlton, as belonging,
+he says, to the class of Shaking Palsies. "Mary Ford, of a sanguineous
+and robust constitution, had an involuntary motion of her right arm,
+occasioned by a fright, which first brought on convulsion fits, and
+most excruciating pain in the stomach, which vanished on a sudden, and
+her right arm was instantaneously flung into an involuntary and
+perpetual motion, like the swing of a pendulum, raising the hand, at
+every vibration higher than her head; but if by any means whatever it
+was stopped; the pain in her stomach came on again, and convulsion
+fits were the certain consequence, which went off when the vibration
+of her hand returned."
+
+Another case, which the Doctor designates as 'A Shaking Palsy,'
+apparently from worms, he describes thus, "A poor boy, about twelve
+or thirteen years of age, was seized with a Shaking Palsy. His legs
+became useless, and together with his head and hands, were in
+continual agitation; after many weeks trial of various remedies, my
+assistance was desired.
+
+"His bowels being cleared, I ordered him a grain of Opium a day in the
+gum pill; and in three or four days the shaking had nearly left him."
+By pursuing this plan, the medicine proving a vermifuge, he could soon
+walk, and was restored to perfect health.
+
+Whether these cases should be classed under Shaking Palsy or not, is
+necessary to be here determined; since, if they are properly ranked,
+the cases which have been described in the preceding pages, differ so
+much from them as certainly to oppose their being classed together:
+and the disease, which is the subject of these pages, cannot be
+considered as the same with Shaking Palsy, as characterised by those
+cases.
+
+The term Shaking Palsy is evidently inapplicable to the first of these
+cases, which appears to have belonged more properly to the genus
+_Convulsio_, of Cullen, or to _Hieranosos_ of Linnaeus and Vogel[10].
+
+    [Footnote 10: Corporis agitatio continua, indolens,
+    convulsiva, cum sensibilitate.--_Linn._
+
+    Agitatio corporis vel artuum convulsiva continua, chronica,
+    cum integritate sensuum.--_Vogel._
+
+    This genus is resolved by Cullen into that of Convulsio.
+    _Synops. Nosol._ 1803.
+
+    Dr. Macbride has given a very interesting and illustrative
+    case of this disease.
+
+    "Hieranasos, or Morbus Sacer, so called, as being vulgarly
+    supposed to arise from witchcraft, or some extraordinary
+    celestial influence, is a distinct genus of disease, though a
+    very uncommon one; the author once had an opportunity of
+    seeing a case. The patient was a lad about seventeen, who at
+    that time had laboured under this extraordinary disease for
+    more than twelve years. His body was so distorted, and the
+    legs and arms so twisted round it, by the continued
+    convulsive working, that no words can give an adequate idea
+    of the oddity of his figure; the agitation of the muscles was
+    perpetual; but in general he did not complain of pain nor
+    sickness; and had his senses perfectly, insomuch that he used
+    to assist his mother, who kept a little school, in teaching
+    children to read." _A methodical Introduction to the Theory
+    and Practice of Physic. By David Macbride, M.D. p. 559._]
+
+The latter appears to be referable to that class of proteal forms of
+disease, generated by a disordered state of primae viae, sympathetically
+affecting the nervous influence in a distant part of the body.
+
+Unless attention is paid to one circumstance, this disease will be
+confounded with those species of passive tremblings to which the term
+Shaking Palsies has frequently been applied. These are, _tremor
+temulentus_, the trembling consequent to indulgence in the drinking of
+spirituous liquors; that which proceeds from the immoderate employment
+of tea and coffee; that which appears to be dependent on advanced age;
+and all those tremblings which proceed from the various circumstances
+which induce a diminution of power in the nervous system. But by
+attending to that circumstance alone, which has been already noted as
+characteristic of mere tremor, the distinction will readily be made.
+If the trembling limb be supported, and none of its muscles be called
+into action, the trembling will cease. In the real Shaking Palsy the
+reverse of this takes place, the agitation continues in full force
+whilst the limb is at rest and unemployed; and even is sometimes
+diminished by calling the muscles into employment.
+
+
+
+
+                               CHAP. IV.
+
+          PROXIMATE CAUSE--REMOTE CAUSES--ILLUSTRATIVE CASES.
+
+
+Before making the attempt to point out the nature and cause of this
+disease, it is necessary to plead, that it is made under very
+unfavourable circumstances. Unaided by previous inquiries immediately
+directed to this disease, and not having had the advantage, in a
+single case, of that light which anatomical examination yields,
+opinions and not facts can only be offered. Conjecture founded on
+analogy, and an attentive consideration of the peculiar symptoms of
+the disease, have been the only guides that could be obtained for this
+research, the result of which is, as it ought to be, offered with
+hesitation.
+
+                       SUPPOSED PROXIMATE CAUSE.
+
+     A diseased state of the _medulla spinalis_, in that part
+     which is contained in the canal, formed by the superior
+     cervical vertebrae, and extending, as the disease proceeds,
+     to the _medulla oblongata_.
+
+By the nature of the symptoms we are taught, that the disease depends
+on some irregularity in the direction of the nervous influence; by the
+wide range of parts which are affected, that the injury is rather in
+the source of this influence than merely in the nerves of the parts;
+by the situation of the parts whose actions are impaired, and the
+order in which they become affected, that the proximate cause of the
+disease is in the superior part of the medulla spinalis; and by the
+absence of any injury to the senses and to the intellect, that the
+morbid state does not extend to the encephalon.
+
+Uncertainty existing as to the nature of the proximate cause of this
+disease, its remote causes must necessarily be referred to with
+indecision. Assuming however the state just mentioned as the proximate
+cause, it may be concluded that this may be the result of injuries of
+the medulla itself, or of the theca helping to form the canal in which
+it is inclosed.
+
+The great degree of mobility in that portion of the spine which is
+formed by the superior cervical vertebrae, must render it, and the
+contained parts, liable to injury from sudden distortions. Hence
+therefore may proceed inflammation of quicker or of slower progress,
+disease of the vertebrae, derangement of structure in the medulla, or
+in its membranes, thickening or even ulceration of the theca, effusion
+of fluids, &c.
+
+But in no case which has been noticed, has the patient recollected
+receiving any injury of this kind, or any fixed pain in early life in
+these parts, which might have led to the opinion that the foundation
+for this malady had been thus laid. On the subject indeed of remote
+causes, no satisfactory accounts has yet been obtained from any of the
+sufferers. Whilst one has attributed this affliction to indulgence in
+spirituous liquors, and another to long lying on the damp ground; the
+others have been unable to suggest any circumstance whatever, which,
+in their opinion, could be considered as having given origin, or
+disposed, to the calamity under which they suffered.
+
+Cases illustrative of the nature and cause of this malady are very
+rare. In the following case symptoms very similar are observable, so
+far as affecting the lower extremities. That the medulla spinalis was
+here affected, and in its lower part, is not to be doubted: but this,
+unfortunately, was never ascertained by examination. It must be
+however remarked, that this case differed from those which have been
+given of this disease, in the suddenness with which the symptoms
+appeared.
+
+_A. B._ aged twenty-six years, during a course of mercury for a
+venereal affection, was exposed to severely inclement weather, for
+several hours, and the next morning, complained of extreme pain in the
+back, and of total inability to employ voluntarily the muscles of the
+lower extremities, which were continually agitated with severe
+convulsive motions. The physician who attended him employed those
+means which seemed best calculated to relieve him; but with no
+beneficial effect. The lower extremities were perpetually agitated
+with strong palpitatory motions, and, frequently, three or four times
+in a minute, suddenly raised with great vehemence two or three feet
+from the ground, either in a forward or oblique direction, striking
+one limb against the other, or against the chairs, tables, or any
+substance which stood in the way. To check these inordinate motions,
+no means were in the least effectual, except striking the thighs
+forcibly during the more violent convulsions. No advantage was derived
+from all the means which were employed during upwards of twelvemonths.
+Full ten years after this period, the unhappy subject of this malady
+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.
+
+It must be acknowledged, that in the well-known cases, described by
+Mr. Potts, of that kind of Palsy of the lower limbs which is
+frequently found to accompany a curvature of the spine, and in which a
+carious state of the vertebrae is found to exist, no instructive
+analogy is discoverable; slight convulsive motions may indeed happen
+in the disease proceeding from curvature of the spine; but palpitating
+motions of the limbs, such as belong to the disease here described, do
+not appear to have been hitherto noticed.
+
+Whilst striving to determine the nature and origin of this disease, it
+becomes necessary to give the following particulars of an interesting
+case of Palsy occasioned by a fall, attended with uncommon symptoms,
+related by Dr. Maty, in the third volume of the Medical Observations
+and Inquiries. The subject of this case, the Count de Lordat, had the
+misfortune to be overturned from a pretty high and steep bank. His
+head pitched against the top of the coach, and was bent from left to
+right; his left shoulder, arm, and especially his hand, were
+considerably bruised. At first he felt a good deal of pain along the
+left side of his neck, but neither then, nor at any other time, had he
+any faintings, vomitings, or giddiness.--On the sixth day he was let
+blood, on account of the pain in his shoulder and the contusion of his
+hand, which were then the only symptoms he complained of, and of
+which he soon found himself relieved.--Towards the beginning of the
+following winter, he began to find _a small impediment in uttering
+some words, and his left arm appeared weaker_. In the following
+spring, having suffered considerably from the severities of the winter
+campaign, he found _the difficulty in speaking, and in moving his left
+arm, considerably increased_.--On employing the thermal waters of
+Bourbonne, his speech become freer, but, on his return to Paris, the
+Palsy was increased, and the arm somewhat wasted.--In the beginning of
+the next spring he went to Balaruc; when he became affected with
+_involuntary convulsive motions all over the body_. The left arm
+withered more and more, _a spitting began_, and now it was _with
+difficulty that he uttered a few words_. Frictions and sinapisms were
+successively tried, and an issue, made by a caustic, was kept open for
+some time without any effect; but no mention is made of what part the
+issue was established in.
+
+Soon after this, and three years and a half after the fall, Doctor
+Maty first saw the patient, and gives the following description of
+his situation. "A more melancholy object I never beheld. The patient,
+naturally a handsome, middle-sized, sanguine man, of a cheerful
+disposition, and an active mind, appeared much emaciated, stooping,
+and dejected. _He still walked alone with a cane, from one room to the
+other, but with great difficulty, and in a tottering manner_; his left
+hand and arm were much reduced, and would hardly perform any motion;
+_the right was somewhat benumbed, and he could scarcely lift it up to
+his head; his saliva was continually trickling out of his mouth, and
+he had neither the power of retaining it, nor of spitting it out
+freely_. What words he still could utter were monosyllables, and these
+came out, after much struggle, in a violent expiration, and with such
+a low voice and indistinct articulation, as hardly to be understood
+but by those who were constantly with him. He fetched his breath
+rather hard; his pulse was low, but neither accelerated nor
+intermitting. He took very little nourishment, could chew and swallow
+no solids, and even found great pain in getting down liquids. Milk was
+almost his only food; his body was rather loose, his urine natural,
+his sleep good, his senses, and the powers of his mind, unimpaired; he
+was attentive to, and sensible of every thing which was said in
+conversation, and shewed himself very desirous of joining in it; but
+was continually checked by the impediment in his speech, and the
+difficulty which his hearers were put to. Happily for him he was able
+to read, and as capable as ever of writing, as he shewed me, by
+putting into my hands an account of his present situation, drawn up by
+himself: and I am informed that he spent his time to the very last, in
+writing upon some of the most abstruse subjects."
+
+This gentleman died about four years after the accident, when the body
+was examined by Dr. Bellett and Mons. Sorbier, who made the following
+report:
+
+"We first examined the muscles of the tongue, which were found
+extenuated and of a loose texture. We observed no signs of compression
+in the lingual and brachial nerves, as high as their exit from the
+basis of the cranium and the vertebrae of the neck; but they appeared
+to us more compact than they commonly are, being nearly tendinous. The
+dura mater was in a sound state, but the pia mater was full of blood
+and lymph; on it several hydatids, and towards the falx some marks of
+suppuration were observed. The ventricles were filled with water, and
+the plexus choroides was considerably enlarged, and stuffed with
+grumous blood. The cortical surface of the brain appeared much browner
+than usual, but neither the medullary part nor cerebellum were
+impaired. We chiefly took notice of the Medulla Oblongata, this was
+greatly enlarged, surpassing the usual size by more than one third. It
+was likewise more compact. The membranes, which, in their
+continuation, inclose the spinal marrow, were so tough that we found
+great difficulty in cutting through them, and we observed this to be
+the cause of the tendinous texture of the cervical nerves. The marrow
+itself had acquired such solidity as to elude the pressure of our
+fingers, it resisted as a callous body, and could not be bruised. This
+hardness was observed all along the vertebrae of the neck, but lessened
+by degrees, and was not near so considerable in the vertebrae of the
+thorax. Though the patient was but nine and thirty years old, the
+cartilages of the sternum were ossified, and required as much labour
+to cut them asunder as the ribs; like these they were spungy, but
+somewhat whiter. The lungs and heart were sound. At the bottom of the
+stomach appeared an inflammation, which increased as it extended to
+the intestines. The ileum looked of that dark and livid hue, which is
+observed in membranous parts tending to mortification. The colon was
+not above an inch in diameter, the rectum was smaller still, but both
+appeared sound.--From these appearances, we were at no loss to fix the
+cause of this gradual palsy in the alteration of the medulla spinalis
+and oblongata."
+
+Dr. Bellett offers the following explanation of these changes. "I
+conceive, that, by this accident, the head being violently bent to the
+right, the nervous membranes on the left were excessively stretched
+and irritated; that this cause extended by degrees to the spinal
+marrow, which being thereby compressed, brought on the paralytic
+symptoms, not only of the left arm, but at last in some measure also
+of the right. This induration seems to have been occasioned by the
+constant afflux of the nutritive juices, which were stopt at that
+place, and deprived of their most liquid parts; the grosser ones being
+unable to spread in the boney cavity, by which they were confined,
+could only acquire a greater solidity, and change a soft body into a
+hard and nearly osseous mass. This likewise accounts for the increase
+of the medulla oblongata, which being loaded with more juices than it
+could send off, swelled in the same manner as the branches of trees,
+which will grow of a monstrous size, when the sap that runs into them
+is stopt in its progress. The medulla oblongata not growing so hard as
+the spinalis, was doubtless owing to its not being confined in an
+osseous theca, but surrounded with soft parts, which allowed it room
+to spread. The obstruction from the bulk of this substance must have
+affected the brain, and probably induced the thickening of the pia
+mater, the hydatids, and the beginning of suppuration, whereas the
+dura mater, being of a harder texture, was not injured[11]."
+
+    [Footnote 11: Medical Observations and Inquiries, Vol. III.
+    p. 257.]
+
+In some of the symptoms which appeared in this case, an agreement is
+observable between it and those cases which are mentioned in the
+beginning of these pages. The weakened state of both arms; the power
+first lessening in one arm, and then in a similar manner in the other
+arm; the affection of the speech; the difficulty in chewing and in
+swallowing; as well as of retaining, or freely discharging, the
+spittle; the convulsive motions of the body; and the unimpaired state
+of the intellects; constitute such a degree of accordance as, although
+it may not mark an identity of disease, serves at least to show that
+nearly the same parts were the seat of the disease in both instances.
+Thus we attain something like confirmation of the supposed proximate
+cause, and of one of the assumed occasional causes.
+
+Whilst conjecturing as to the cause of this disease, the following
+collected observations on the effects of injury to the medulla
+spinalis, by Sir Everard Home, become particularly deserving of
+attention. It thence appears, that none of the characteristic symptoms
+of this malady are produced by compression, laceration, or complete
+division of the medulla spinalis.
+
+"Pressure upon the medulla spinalis of the neck, by coagulated blood,
+produced paralytic affections of the arms and legs; all the functions
+of the internal organs were carried on for thirty-five days, but the
+urine and stools passed involuntarily[12].
+
+    [Footnote 12: A coagulum of blood, the thickness of a
+    crown-piece, was found lying upon the external surface of the
+    dura-matral covering of the medulla spinalis, extending from
+    the fourth vertebra colli to the second vertebra dorsi. The
+    medulla spinalis itself was uninjured.]
+
+"Blood extravasated in the central part of the medulla, in the neck,
+was attended with paralytic affection of the legs, but not of the
+arms[13].
+
+    [Footnote 13: The sixth and seventh vertebra colli were
+    dislocated, the medulla spinalis, externally, was uninjured;
+    but in the centre of its substance, just at that part, there
+    was a coagulum of blood nearly two inches in length.]
+
+"In a case where the substance of the medulla was lacerated in the
+neck, there was a paralysis in all the parts below the laceration, the
+lining of the oesophagus was so sensible, that solids could not be
+swallowed, on account of the pain they occasioned[14].
+
+    [Footnote 14: The seventh vertebra colli was fractured, and
+    the medulla spinalis passing through it, was lacerated and
+    compressed.]
+
+"When the medulla of the back was completely divided, there was
+momentary loss of sight, loss of memory for fifteen minutes, and
+permanent insensibility in all the lower parts of the body. The skin
+above the division of the spinal marrow perspired, that below did not.
+The wounded spinal marrow appeared to be extremely sensible[15]."
+_Philosophical Transactions_, 1816, p. 485.
+
+    [Footnote 15: The spinal marrow, within the canal of the
+    sixth vertebra dorsi, was completely destroyed by a musket
+    ball. The person lived four days.]
+
+In two of the cases already noticed, symptoms of rheumatism had
+previously existed; and in Case IV. the right arm, in which the
+palpitation began, was said to have been very violently affected with
+rheumatic pain to the fingers ends. The consideration of this case, in
+which the palpitation had been preceded, at a considerable distance of
+time, by this painful affection of the arm, led to the supposition
+that this latter circumstance might be the cause of the palpitations,
+and the other subsequent symptoms of this disease. This supposition
+naturally occasioned the attention to be eagerly fixed on the
+following case; and of course influenced the mode of treatment which
+was adopted.
+
+_A. B._ subject to rheumatic affection of the deltoid muscle, had felt
+the usual inconveniences from it for two or three days; but at night
+found the pain had extended down the arm, along the inside of the
+fore-arm, and on the sides of the fingers, in which a continual
+tingling was felt. The pain, without being extremely intense, was such
+as effectually to prevent sleep: and seemed to follow the course of
+the brachial nerve. Whilst ascertaining the propriety of this
+conclusion, the pain was found to ramify, as it were, on the fore and
+back part of the chest; and was slightly augmented by drawing a deep
+breath.
+
+These circumstances suggested the probability of slight inflammation,
+or increased determination to the origin of the nerves of these parts,
+and to the neighbouring medulla. On this ground, blood was taken from
+the back part of the neck, by cupping; hot fomentations were applied
+for about the space of an hour, when the upper part of the back of the
+neck was covered with a blister, perspiration was freely induced by
+two or three small doses of antimonials, and the following morning the
+bowels were evacuated by an appropriate dose of calomel. On the
+following day the pains were much diminished, and in the course of
+four or five days were quite removed. The arm and hand felt now more
+than ordinarily heavy, and were evidently much weakened: aching, and
+feeling extremely wearied after the least exertion. The strength of
+the arm was not completely recovered at the end of more than
+twelvemonths; and, after more than twice that time, exertion would
+excite the feeling of painful weariness, but no palpitation or other
+unpleasant symptom has occurred during the five or six years which
+have since passed.
+
+The commencement, progress, and termination of this attack; with the
+success attending the mode of treatment, and the symptoms which
+followed, seem to lead to the conjecture, that the proximate cause of
+the disease, in this case, existed in the medulla spinalis, and that
+it might, if neglected, have gradually resolved itself into that
+disease which is the object of our present inquiry.
+
+Some few months after the occurrence of the preceding case, the writer
+of these lines was called to a female about forty years of age,
+complaining of great pain in both the arms, extending from the
+shoulder to the finger ends. She stated, that she was attacked in the
+same manner as is described in the preceding case, about nine months
+before; that the complaint was considered as rheumatism, and was not
+benefited by any of the medicines which had been employed; but that
+after three or four weeks it gradually amended, leaving both the arms
+and hands in a very weakened and trembling state. From this state they
+were now somewhat recovered; but she was extremely anxious, fearing
+that if the present attack should not be soon checked, she might
+entirely lose the use of her hands and arms.
+
+Instructed by the preceding case, similar means were here recommended.
+Leeches, stimulating fomentations, and a blister, which was made for
+sometime to yield a purulent discharge, were applied over the cervical
+vertebrae; and in the course of a very few days the pain was entirely
+removed. It is regretted that no farther information, as to the
+progress of this case, could be obtained.
+
+On meeting with these two cases, it was thought that it might not be
+improbable that attacks of this kind, considered at the time merely as
+rheumatic affections, might lay the foundation of this lamentable
+disease, which might manifest itself at some distant period, when the
+circumstance in which it had originated, had, perhaps, almost escaped
+the memory. Indeed when it is considered that neither in the ordinary
+cases of Palsy of the lower extremities, proceeding from diseased
+spine, nor in cases of injured medulla from fractured vertebrae, any of
+the peculiar symptoms of this disease are observable, we necessarily
+doubt as to the probability of its being the direct effect of any
+sudden injury. But taking all circumstances into due consideration,
+particularly the very gradual manner in which the disease commences,
+and proceeds in its attacks; as well as the inability to ascribe its
+origin to any more obvious cause, we are led to seek for it in some
+slow morbid change in the structure of the medulla, or its investing
+membranes, or theca, occasioned by simple inflammation, or rheumatic
+or scrophulous affection.
+
+It must be too obvious that the evidence adduced as to the nature of
+the proximate and occasional causes of this disease, is by no means
+conclusive. A reference to the test therefore which will be yielded by
+an examination of some of the more prominent symptoms, especially as
+to their agreement with the supposed proximate cause, is more
+particularly demanded. Satisfied as to the importance of this part of
+the present undertaking, no apology is offered for the extent to which
+the examination is carried on.
+
+If the palpitation and the attendant weakness of the limbs, &c. be
+considered as to the order in which the several parts are attacked, it
+is believed, that some confirmation will be obtained of the opinion
+which has been just offered, respecting the cause, or at least the
+seat, of that change which may be considered as the proximate cause of
+this disease.
+
+One of the arms, in all the cases which have been here mentioned, has
+been the part in which these symptoms have been first noticed; the
+legs, head, and trunk have then become gradually affected, and lastly,
+the muscles of the mouth and fauces have yielded to the morbid
+influence.
+
+The arms, the parts first manifesting disordered action, of course
+direct us, whilst searching for the cause of these changes, to the
+brachial nerves. But finding the mischief extending to other parts,
+not supplied with these, but with other nerves derived from nearly the
+same part of the medulla spinalis, we are of course led to consider
+that portion of the medulla spinalis itself, from which these nerves
+are derived, as the part in which those changes have taken place,
+which constitute the proximate cause of this disease.
+
+From the subsequent affection of the lower extremities, and from the
+failure of power in the muscles of the trunk, such a change in the
+substance of the medulla spinalis may be inferred, as shall have
+considerably interrupted, and interfered with, the extension of the
+nervous influence to those parts, whose nerves are derived from any
+portion of the medulla below the part which has undergone the diseased
+change.
+
+The difficulty in supporting the trunk erect, as well as the
+propensity to the adopting of a hurried pace, is also referable to
+such a diminution of the nervous power in the extensor muscles of the
+head and trunk, as prevents them from performing the offices of
+maintaining the head and body in an erect position.
+
+From the impediment to speech, the difficulty in mastication and
+swallowing, the inability to retain, or freely to eject, the Saliva,
+may with propriety be inferred an extension of the morbid change
+upwards through the medulla spinalis to the medulla oblongata,
+necessarily impairing the powers of the several nerves derived from
+that portion into which the morbid change may have reached. In the
+late occurrence of this set of symptoms, and the extension upwards of
+the diseased state, a very close agreement is observable between this
+disease and that which has been already shown, proved fatal to the
+Count de Lordat. But in this case, the disease doubtlessly became
+differently modified, and its symptoms considerably accelerated, in
+consequence of the magnitude of the injury by which the disease was
+induced.
+
+
+
+
+                               CHAP. V.
+
+             CONSIDERATIONS RESPECTING THE MEANS OF CURE.
+
+
+The inquiries made in the preceding pages yield, it is to be much
+regretted, but little more than evidence of inference: nothing direct
+and satisfactory has been obtained. All that has been ventured to
+assume here, has been that the disease depends on a disordered state
+of that part of the medulla which is contained in the cervical
+vertebrae. But of what nature that morbid change is; and whether
+originating in the medulla itself, in its membranes, or in the
+containing theca, is, at present, the subject of doubt and conjecture.
+But although, at present, uninformed as to the precise nature of the
+disease, still it ought not to be considered as one against which
+there exists no countervailing remedy.
+
+On the contrary, there appears to be sufficient reason for hoping that
+some remedial process may ere long be discovered, by which, at least,
+the progress of the disease may be stopped. It seldom happens that
+the agitation extends beyond the arms within the first two years;
+which period, therefore, if we were disposed to divide the disease
+into stages, might be said to comprise the first stage. In this
+period, it is very probable, that remedial means might be employed
+with success: and even, if unfortunately deferred to a later period,
+they might then arrest the farther progress of the disease, although
+the removing of the effects already produced, might be hardly to be
+expected.
+
+From a review of the changes which had taken place in the case of
+Count de Lordat, it seems as if we were able to trace the order and
+mode in which the morbid changes may proceed in this disease. From any
+occasional cause, the thecal ligament, the membranes, or the medulla
+itself, may pass into the state of simple excitement or irritation,
+which may be gradually succeeded by such a local afflux and
+determination of blood into the minute vessels, as may terminate in
+actual but slow inflammation. The result of this would be a
+thickening of the theca, or membranes, and perhaps an increase in the
+volume of the medulla itself, which would gradually occasion such a
+degree of pressure against the sides of the unyielding canal, as must
+eventually intercept the influence of the brain upon the inferior
+portion of the medullary column, and upon the parts on which the
+nerves of this portion are disposed.
+
+From this review, and assuming that the morbid changes in this disease
+may not be widely dissimilar from those which occurred in the case of
+Count de Lordat, the chance of relief from the proposed mode of
+treatment may appear to be sufficient to warrant its trial.
+
+In such a case then, at whatever period of the disease it might be
+proposed to attempt the cure, blood should be first taken from the
+upper part of the neck, unless contra-i(n)dicated by any particul(ar)
+circumstance. After which vesicatories should be applied to the (sa)me
+part, and a purulent discharge obtained by appropriate use of the
+Sabine Liniment; having recourse to the application of a fresh
+blister, when from the diminution of the discharging surface, pus is
+not secreted in a sufficient quantity. Should the blisters be found
+too inconvenient, or a sufficient quantity of discharge not be
+obtained thereby, an issue of at least an inch and a half in length
+might be established on each side of the vertebral columna, in its
+superior part. These, it is presumed, would be best formed with
+caustic, and kept open with any proper substance[16].
+
+    [Footnote 16: Cork, which has been hitherto neglected,
+    appears to be very appropriate to this purpose. It possesses
+    lightness, softness, elasticity and sufficient firmness; and
+    is also capable of being readily fashioned to any convenient
+    form. The form which it seems would be best adapted to the
+    part, is that of an almond, or of the variety of bean called
+    scarlet bean; but at least an inch and a half in length.]
+
+Could it have been imagined that such considerable benefit: indeed,
+that such astonishing cures, could have been effected by issues in
+cases of Palsy of the lower extremities from diseased spine? although
+satisfied with ascribing those cases to scrofulous action, we are in
+fact as little informed respecting the nature of the affection,
+inducing the carious state of the vertebrae, as we are respecting the
+peculiar change of structure which takes place in this disease.
+Equally uninformed are we also as to the peculiar kind of morbid
+action, which takes place in the ligaments of the joints; as well as
+that which takes place in different instances of deep seated pains and
+affections of the parts contained in the head, thorax, and abdomen,
+and in all which cases the inducing of a purulent discharge in their
+neighbourhood is so frequently productive of a cure. Experiment has
+not indeed been yet employed to prove, but analogy certainly warrants
+the hope, that similar advantages might be derived from the use of the
+means enumerated, in the present disease. It is obvious, that the
+chance of obtaining relief will depend in a great measure on the
+period at which the means are employed. As in every other disease, so
+here, the earlier the remedies are resorted to, the greater will be
+the probability of success. But in this disease there is one
+circumstance which demands particular attention; the long period to
+which it may be extended. One of its peculiar symptoms, Scelotyrbe
+festinans, may not occur until the disease has existed ten or twelve
+years, or more; hence, when looking for the period, within which our
+hopes of remedial aid is to be limited; we may, guided by the slow
+progress of the malady, extend it to a great length, when compared
+with that within which we should be obliged to confine ourselves in
+most other diseases.
+
+But it is much to be apprehended, as in many other cases, that the
+resolution of the patients will seldom be sufficient to enable them to
+persevere through the length of time which the proposed process will
+necessarily require. As slow as is the progress of the disease, so
+slow in all probability must be the period of the return to health. In
+most cases, especially in those in which the disease has been allowed
+to exist long unopposed, it may be found that all that art is capable
+of accomplishing, is that of checking its further progress. Nor will
+this be regarded as a trifle, when, by reference to the history of the
+disease, is seen the train of harassing evils which would be thus
+avoided.
+
+But it seems as if there existed reason for hoping for more. For
+supposing change of structure to have taken place, it is extremely
+probable that this change may be merely increase in mass or volume by
+interstitial addition, the consequence of increased action in the
+minute vessels of the part. In that case, should the instituting of a
+purulent discharge, in a neighbouring part, act in the manner which we
+would presume it may--should it by keeping up a constant discharge,
+not merely alter the determination, but diminish the inordinate action
+of the vessels in the diseased part; and at the same time excite the
+absorbents to such increased action as may remove the added matter;
+there will exist strong ground for hope, that a happy, though slow
+restoration to health, may be obtained.
+
+Until we are better informed respecting the nature of this disease,
+the employment of internal medicines is scarcely warrantable; unless
+analogy should point out some remedy the trial of which rational hope
+might authorize. Particular circumstances indeed must arise in
+different cases, in which the aid of medicine may be demanded: and the
+intelligent will never fail to avail themselves of any opportunity of
+making trial of the influence of mercury, which has in so many
+instances, manifested its power in correcting derangement of
+structure.
+
+The weakened powers of the muscles in the affected parts is so
+prominent a symptom, as to be very liable to mislead the inattentive,
+who may regard the disease as a mere consequence of constitutional
+debility. If this notion be pursued, and tonic medicines, and highly
+nutritious diet be directed, no benefit is likely to be thus obtained;
+since the disease depends not on general weakness, but merely on the
+interruption of the flow of the nervous influence to the affected
+parts.
+
+It is indeed much to be regretted that this malady is generally
+regarded by the sufferers in this point of view, so discouraging to
+the employment of remedial means. Seldom occurring before the age of
+fifty, and frequently yielding but little inconvenience for several
+months, it is generally considered as the irremediable diminution of
+the nervous influence, naturally resulting from declining life; and
+remedies therefore are seldom sought for.
+
+Although unable to trace the connection by which a disordered state of
+the stomach and bowels may induce a morbid action in a part of the
+medulla spinalis, yet taught by the instruction of Mr. Abernethy,
+little hesitation need be employed before we determine on the
+probability of such occurrence. The power, possessed by sympathy, of
+inducing such disordered action in a distant part, and the probability
+of such disordered action producing derangement of structure, can
+hardly be denied. The following Case seems to prove, at least, that
+the mysterious sympathetic influence which so closely simulates the
+forms of other diseases, may induce such symptoms as would seem to
+menace the formation of a disease not unlike to that which we have
+been here treating of.
+
+_A. B._ A man, 54 years of age, of temperate habits and regular state
+of bowels, became gradually affected with slight numbness and
+prickling, with a feeling of weakness in both arms, accompanied by a
+sense of fulness about the shoulders, as if produced by the pressure
+of a strong ligature; and at times a slight trembling of the hands.
+During the night, the fullness, numbness, and prickling were much
+increased. The appetite had been diminished for several weeks; and the
+abdomen, on being examined, felt as though containing considerable
+accumulation.
+
+Before adopting any other measures, and as there appeared to be no
+marks of vascular fulness, it was determined to empty the bowels. This
+was done effectually by moderate doses of calomel, with the occasional
+help of Epsom salts; and in about ten days, by these means alone, the
+complaints were entirely removed.
+
+Before concluding these pages, it may be proper to observe once more,
+that an important object proposed to be obtained by them is, the
+leading of the attention of those who humanely employ anatomical
+examination in detecting the causes and nature of diseases,
+particularly to this malady. By their benevolent labours its real
+nature may be ascertained, and appropriate modes of relief, or even of
+cure, pointed out.
+
+To such researches the healing art is already much indebted for the
+enlargement of its powers of lessening the evils of suffering
+humanity. Little is the public aware of the obligations it owes to
+those who, led by professional ardour, and the dictates of duty, have
+devoted themselves to these pursuits, under circumstances most
+unpleasant and forbidding. Every person of consideration and feeling,
+may judge of the advantages yielded by the philanthropic exertions of
+a HOWARD; but how few can estimate the benefits bestowed on mankind,
+by the labours of a MORGAGNI, HUNTER, or BAILLIE.
+
+
+                                FINIS.
+
+
+
+
+
+End of Project Gutenberg's An Essay on the Shaking Palsy, by James Parkinson
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