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diff --git a/23777-8.txt b/23777-8.txt new file mode 100644 index 0000000..a8ed5e3 --- /dev/null +++ b/23777-8.txt @@ -0,0 +1,1803 @@ +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 Boė. 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 asthenię +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 Nosologię Methodicę.--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 fęces 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 fęces 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 fęces, 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 Boė 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, imperfectę ac imbecillę + observantur fieri eadem functiones, in motu tremulo et + infirmo, nec diu durante, in visu debili, ac mox defatigato, + &c. + + Sect. XIX. Inęqualiter, inordinatč, ac pręter 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 + inordinatč 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, quę 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 +Boė) 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, ęqualibus temporum intervallis, non + musculus, sed artus ipsemet alternatim attollitur aut + deprimitur, aut in oppositas partes it atque redit per minima + tamen spatiola; in palpitatione verņ 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 Quęrenda sit, ignoramus. _Nosologię + Methodicę_, 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 + pręcurrunt. Vitium loquelę 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 prętervisa referenda videtur, quam non aptius + nominari posse putem quąm scelotyrbem festinantem, seu + festiniam. + + SECT. II. _Scelotyrbe festinans_: est peculiaris scelotyrbes + species in qua ęgri solito more dum gradi volunt currere + coguntur, quod videre est apud D. Carquet, et observavit + Leydę illustr. Gaubius. _Patholog. instit._ 751, et in + loquela hęc _volubilitas_ dicitur quā lingua pręcurrit + mentem. Video actu mulierem sexagenariam hoc affectam morbo + siccitati nervorum tribuendo; laborat enim rheumatismo sicco, + seu ab acrimonia sanguinis, dolores nocte a calore + recrudescunt, ą thermis non sublevantur: ei pręscripsi + phlebotomiam, et pręmissis jusculis ex lactucā, endiviā, 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 pręcipiti 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 prąxi 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 Boė 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 Linnęus 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 primę vię, 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 vertebrę, 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 vertebrę, 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 vertebrę, 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 vertebrę 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 vertebrę 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 vertebrę of the neck, but lessened +by degrees, and was not near so considerable in the vertebrę 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 +vertebrę; 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 vertebrę, 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 +vertebrę. 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 vertebrę, 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 + +*** END OF THIS PROJECT GUTENBERG EBOOK AN ESSAY ON THE SHAKING PALSY *** + +***** This file should be named 23777-8.txt or 23777-8.zip ***** +This and all associated files of various formats will be found in: + http://www.gutenberg.org/2/3/7/7/23777/ + +Produced by Irma Spehar and the Online Distributed +Proofreading Team at http://www.pgdp.net + + +Updated editions will replace the previous one--the old editions +will be renamed. + +Creating the works from public domain print editions means that no +one owns a United States copyright in these works, so the Foundation +(and you!) can copy and distribute it in the United States without +permission and without paying copyright royalties. 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