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 whichhypothetical statements are admitted, are in no instance more obviousthan in those sciences which more particularly belong to the healingart. It therefore is necessary, that some conciliatory explanationshould be offered for the present publication: in which, it isacknowledged, that mere conjecture takes the place of experiment; and, that analogy is the substitute for anatomical examination, the onlysure foundation for pathological knowledge. When, however, the nature of the subject, and the circumstances underwhich it has been here taken up, are considered, it is hoped that theoffering of the following pages to the attention of the medicalpublic, will not be severely censured. The disease, respecting whichthe present inquiry is made, is of a nature highly afflictive. Notwithstanding which, it has not yet obtained a place in theclassification of nosologists; some have regarded its characteristicsymptoms as distinct and different diseases, and others have given itsname to diseases differing essentially from it; whilst the unhappysufferer has considered it as an evil, from the domination of which hehad no prospect of escape. The disease is of long duration: to connect, therefore, the symptomswhich occur in its later stages with those which mark itscommencement, 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 ofavailing himself; and has hence been led particularly to observeseveral other cases in which the disease existed in different stagesof its progress. By these repeated observations, he hoped that he hadbeen led to a probable conjecture as to the nature of the malady, andthat analogy had suggested such means as might be productive ofrelief, and perhaps even of cure, if employed before the disease hadbeen too long established. He therefore considered it to be a duty tosubmit his opinions to the examination of others, even in theirpresent 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 ofascertaining its nature and cause by anatomical investigation, did notseem likely to be taken up by those who, from their abilities andopportunities, were most likely to accomplish it. That these friendsto humanity and medical science, who have already unveiled to us manyof the morbid processes by which health and life is abridged, might beexcited to extend their researches to this malady, was much desired;and it was hoped, that this might be procured by the publication ofthese remarks. Should the necessary information be thus obtained, the writer willrepine at no censure which the precipitate publication of mereconjectural suggestions may incur; but shall think himself fullyrewarded by having excited the attention of those, who may point outthe most appropriate means of relieving a tedious and most distressingmalady. CONTENTS. CHAP. I. PAGEDEFINITION—HISTORY—ILLUSTRATIVE CASES 1 CHAP. II. PATHOGNOMONIC SYMPTOMS EXAMINED—TREMORCOACTUS—SCELOTYRBE FESTINANS 19 CHAP. III. SHAKING PALSY DISTINGUISHED FROM OTHER DISEASESWITH WHICH IT MAY BE CONFOUNDED 27 CHAP. IV. PROXIMATE CAUSE—REMOTE CAUSES—ILLUSTRATIVECASES 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 ingeneral. By some it has been used to designate ordinary cases ofPalsy, in which some slight tremblings have occurred; whilst by othersit has been applied to certain anomalous affections, not belonging toPalsy. The shaking of the limbs belonging to this disease was particularlynoticed, as will be seen when treating of the symptoms, by Galen, whomarked its peculiar character by an appropriate term. The samesymptom, it will also be seen, was accurately treated of by Sylvius dela Boë. Juncker also seems to have referred to this symptom: havingdivided tremor into active and passive, he says of the latter, “adaffectus semiparalyticos pertinent; de qualibus hic agimus, quique_tremores paralytoidei_ vocantur. ” Tremor has been adopted, as agenus, by almost every nosologist; but always unmarked, in theirseveral definitions, by such characters as would embrace this disease. The celebrated Cullen, with his accustomed accuracy observes, “Tremorem, utpote semper symptomaticum, in numerum generum reciperenollem; species autem a Sauvagesio recensitas, prout mihi vel astheniævel paralysios, vel convulsionis symptomata esse videntur, hissubjungam[1]. ” Tremor can indeed only be considered as a symptom, although several species of it must be admitted. In the presentinstance, the agitation produced by the peculiar species of tremor, which here occurs, is chosen to furnish the epithet by which thisspecies 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 thismalady, and so extremely slow is its progress, that it rarely happens, that the patient can form any recollection of the precise period ofits commencement. The first symptoms perceived are, a slight sense ofweakness, 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 atan uncertain period, but seldom in less than twelvemonths or more, themorbid influence is felt in some other part. Thus assuming one of thehands and arms to be first attacked, the other, at this periodbecomes similarly affected. After a few more months the patient isfound to be less strict than usual in preserving an upright posture:this being most observable whilst walking, but sometimes whilstsitting or standing. Sometime after the appearance of this symptom, and during its slow increase, one of the legs is discovered slightlyto tremble, and is also found to suffer fatigue sooner than the leg ofthe other side: and in a few months this limb becomes agitated bysimilar 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, wouldperhaps seldom think of his being the subject of disease, except whenreminded of it by the unsteadiness of his hand, whilst writing oremploying himself in any nicer kind of manipulation. But as thedisease proceeds, similar employments are accomplished withconsiderable difficulty, the hand failing to answer with exactness tothe dictates of the will. Walking becomes a task which cannot beperformed without considerable attention. The legs are not raised tothat height, or with that promptitude which the will directs, so thatthe utmost care is necessary to prevent frequent falls. At this period the patient experiences much inconvenience, whichunhappily is found daily to increase. The submission of the limbs tothe directions of the will can hardly ever be obtained in theperformance of the most ordinary offices of life. The fingers cannotbe disposed of in the proposed directions, and applied with certaintyto any proposed point. As time and the disease proceed, difficultiesincrease: 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 toraise the morsel from the plate: which, when seized, is with muchdifficulty conveyed to the mouth. At this period the patient seldomexperiences a suspension of the agitation of his limbs. Commencing, for instance in one arm, the wearisome agitation is borne untilbeyond sufferance, when by suddenly changing the posture it is for atime stopped in that limb, to commence, generally, in less than aminute in one of the legs, or in the arm of the other side. Harassedby this tormenting round, the patient has recourse to walking, a modeof exercise to which the sufferers from this malady are in generalpartial; owing to their attention being thereby somewhat diverted fromtheir unpleasant feelings, by the care and exertion required to ensureits safe performance. But as the malady proceeds, even this temporary mitigation ofsuffering from the agitation of the limbs is denied. The propensity tolean forward becomes invincible, and the patient is thereby forced tostep on the toes and fore part of the feet, whilst the upper part ofthe body is thrown so far forward as to render it difficult to avoidfalling on the face. In some cases, when this state of the malady isattained, the patient can no longer exercise himself by walking in hisusual manner, but is thrown on the toes and forepart of the feet;being, at the same time, irresistibly impelled to take much quickerand shorter steps, and thereby to adopt unwillingly a running pace. Insome cases it is found necessary entirely to substitute running forwalking; since otherwise the patient, on proceeding only a very fewpaces, would inevitably fall. In this stage, the sleep becomes much disturbed. The tremulous motionof the limbs occur during sleep, and augment until they awaken thepatient, and frequently with much agitation and alarm. The power ofconveying the food to the mouth is at length so much impeded that heis obliged to consent to be fed by others. The bowels, which had beenall along torpid, now, in most cases, demand stimulating medicines ofvery considerable power: the expulsion of the fæces from the rectumsometimes requiring mechanical aid. As the disease proceeds towardsits last stage, the trunk is almost permanently bowed, the muscularpower is more decidedly diminished, and the tremulous agitationbecomes violent. The patient walks now with great difficulty, andunable any longer to support himself with his stick, he dares notventure on this exercise, unless assisted by an attendant, who walkingbackwards before him, prevents his falling forwards, by the pressureof his hands against the fore part of his shoulders. His words are nowscarcely intelligible; and he is not only no longer able to feedhimself, but when the food is conveyed to the mouth, so much are theactions of the muscles of the tongue, pharynx, &c. Impeded by impairedaction and perpetual agitation, that the food is with difficultyretained in the mouth until masticated; and then as difficultlyswallowed. Now also, from the same cause, another very unpleasantcircumstance occurs: the saliva fails of being directed to the backpart of the fauces, and hence is continually draining from the mouth, mixed with the particles of food, which he is no longer able to clearfrom the inside of the mouth. As the debility increases and the influence of the will over themuscles fades away, the tremulous agitation becomes more vehement. Itnow seldom leaves him for a moment; but even when exhausted natureseizes a small portion of sleep, the motion becomes so violent as notonly to shake the bed-hangings, but even the floor and sashes of theroom. The chin is now almost immoveably bent down upon the sternum. The slops with which he is attempted to be fed, with the saliva, arecontinually trickling from the mouth. The power of articulation islost. The urine and fæces are passed involuntarily; and at the last, constant sleepiness, with slight delirium, and other marks of extremeexhaustion, announce the wished-for release. CASE I. Almost every circumstance noted in the preceding description, wasobserved in a case which occurred several years back, and which, fromthe particular symptoms which manifested themselves in its progress;from the little knowledge of its nature, acknowledged to be possessedby the physician who attended; and from the mode of its termination;excited an eager wish to acquire some further knowledge of its natureand cause. The subject of this case was a man rather more than fifty years ofage, who had industriously followed the business of a gardener, leading a life of remarkable temperance and sobriety. The commencementof the malady was first manifested by a slight trembling of the lefthand and arm, a circumstance which he was disposed to attribute to hishaving been engaged for several days in a kind of employment requiringconsiderable exertion of that limb. Although repeatedly questioned, hecould recollect no other circumstance which he could consider ashaving been likely to have occasioned his malady. He had not sufferedmuch from Rheumatism, or been subject to pains of the head, or hadever experienced any sudden seizure which could be referred toapoplexy or hemiplegia. In this case, every circumstance occurredwhich has been mentioned in the preceding history. CASE II. The subject of the case which was next noticed was casually met within the street. It was a man sixty-two years of age; the greater partof 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 theextremities were considerably agitated, the speech was very muchinterrupted, and the body much bowed and shaken. He walked almostentirely on the fore part of his feet, and would have fallen everystep if he had not been supported by his stick. He described thedisease as having come on very gradually, and as being, according tohis full assurance, the consequence of considerable irregularities inhis mode of living, and particularly of indulgence in spirituousliquors. He was the inmate of a poor-house of a distant parish, andbeing fully assured of the incurable nature of his complaint, declinedmaking any attempts for relief. CASE III. The next case was also noticed casually in the street. The subject ofit was a man of about sixty-five years of age, of a remarkableathletic frame. The agitation of the limbs, and indeed of the head andof the whole body, was too vehement to allow it to be designated astrembling. 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 continuedrun, and to employ his stick every five or six steps to force him moreinto an upright posture, by projecting the point of it with greatforce against the pavement. He stated, that he had been a sailor, andattributed his complaints to having been for several months confinedin a Spanish prison, where he had, during the whole period of hisconfinement, lain upon the bare damp earth. The disease had herecontinued so long, and made such a progress, as to afford little or noprospect of relief. He besides was a poor mendicant, requiring as wellas the means of medical experiment, those collateral aids which hecould only obtain in an hospital. He was therefore recommended to maketrial 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 aboutfifty-five years, who had first experienced the trembling of the armsabout five years before. His application was on account of aconsiderable degree of inflammation over the lower ribs on the leftside, which terminated in the formation of matter beneath the fascia. About a pint was removed on making the necessary opening; and aconsiderable quantity discharged daily for two or three weeks. On hisrecovery from this, no change appeared to have taken place in hisoriginal complaint; and the opportunity of learning its futureprogress 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, andthe gentleman, the lamented subject of which was only seen at adistance, one of the characteristic symptoms of this malady, theinability for motion, except in a running pace, appeared to exist inan extraordinary degree. It seemed to be necessary that the gentlemanshould be supported by his attendant, standing before him with a handplaced on each shoulder, until, by gently swaying backward andforward, he had placed himself in equipoise; when, giving the word, hewould start in a running pace, the attendant sliding from before himand running forward, being ready to receive him and prevent hisfalling, after his having run about twenty paces. CASE VI. In a case which presented itself to observation since thoseabove-mentioned, every information as to the progress of the maladywas very readily obtained. The gentleman who was the subject of it isseventy-two years of age. He has led a life of temperance, and hasnever been exposed to any particular situation or circumstance whichhe can conceive likely to have occasioned, or disposed to thiscomplaint; which he rather seems to regard as incidental upon hisadvanced age, than as an object of medical attention. He howeverrecollects, that about twenty years ago, he was troubled withlumbago, which was severe and lasted some time. About eleven ortwelve, or perhaps more, years ago, he first perceived weakness in theleft hand and arm, and soon after found the trembling commence. Inabout three years afterwards the right arm became affected in asimilar manner: and soon afterwards the convulsive motions affectedthe whole body, and began to interrupt the speech. In about threeyears from that time the legs became affected. Of late years theaction of the bowels had been very much retarded; and at two or threedifferent periods had, with great difficulty, been made to yield tothe action of very strong cathartics. But within the last twelvemonthsthis difficulty has not been so great; perhaps owing to an increasedsecretion of mucus, which envelopes the passing fæces, and whichprecedes and follows their discharge in considerable quantity. About a year since, on waking in the night, he found that he hadnearly lost the use of the right side, and that the face was muchdrawn to the left side. His medical attendant saw him the followingday, when he found him languid, with a small and quick pulse, andwithout pain in the head or disposition to sleep. Nothing moretherefore was done than to promote the action of the bowels, and applya blister to the back of the neck, and in about a fortnight the limbshad entirely recovered from their palsied state. During the time oftheir having remained in this state, neither the arm nor the leg ofthe paralytic side was in the least affected with the tremulousagitation; but as their paralysed state was removed, the shakingreturned. At present he is almost constantly troubled with the agitation, whichhe describes as generally commencing in a slight degree, and graduallyincreasing, until it arises to such a height as to shake the room;when, by a sudden and somewhat violent change of posture, he is almostalways able to stop it. But very soon afterwards it will commence insome other limb, in a small degree, and gradually increase inviolence; but he does not remember the thus checking of it, to havebeen followed by any injurious effect. When the agitation had notbeen thus interrupted, he stated, that it gradually extended throughall the limbs, and at last affected the whole trunk. To illustrate hisobservation as to the power of suspending the motion by a suddenchange of posture, he, being then just come in from a walk, with everylimb shaking, threw himself rather violently into a chair, and said, “Now I am as well as ever I was in my life. ” The shaking completelystopped; but returned within two minutes' time. He now possessed but little power in giving a required direction tothe motions of any part. He was scarcely able to feed himself. He hadwritten hardly intelligibly for the last three years; and at presentcould not write at all. His attendants observed, that of late thetrembling would sometimes begin in his sleep, and increase until itawakened him: when he always was in a state of agitation and alarm. On being asked if he walked under much apprehension of fallingforwards? he said he suffered much from it; and replied in theaffirmative to the question, whether he experienced any difficulty inrestraining himself from getting into a running pace? It being asked, if whilst walking he felt much apprehension from the difficulty ofraising his feet, if he saw a rising pebble in his path? he avowed, ina strong manner, his alarm on such occasions; and it was observed byhis wife, that she believed, that in walking across the room, he wouldconsider as a difficulty the having to step over a pin. The preceding cases appear to belong to the same species: differingfrom each other, perhaps, only in the length of time which the diseasehad 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 theaccompanying cases, that certain affections, the tremulous agitations, and the almost invincible propensity to run, when wishing only towalk, each of which has been considered by nosologists as distinctdiseases, appear to be pathognomonic symptoms of this malady. Todetermine in which of these points of view these affections ought tobe regarded, an examination into their nature, and an inquiry into theopinions of preceding writers respecting them, seem necessary to beattempted. * * * * * I. _Involuntary tremulous motion, with lessened voluntary muscularpower, in parts, not in action, and even supported. _ It is necessary that the peculiar nature of this tremulous motionshould be ascertained, as well for the sake of giving to it itsproper 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 proceedingfrom 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 Sylviusde la Boë into those tremors which are produced by attempts atvoluntary 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 issupported, 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, thatSauvages, by this just distinction, actually separates this kind oftremulous motion, and which is the kind peculiar to this disease, fromthe Genus Tremor. In doing this he is fully warranted by theobservations of Galen on the same subject, as noticed by VanSwieten[5]. “Binas has tremoris species[6] Galenus subtiliterdistinxit, atque etiam diversis nominibus insignivit, tremor enim(τϱὁμ &) facultatis corpus moventis et vehentis infirmitateoboritur. Quippe nemo, qui artus movere non instituerit tremet. Palpitantes autem partes, etiam in quiete fuerint, etiamsi nullumillis motum induxeris palpitant. Ideo primam (_posteriorem_) mododescriptam tremoris speciem, quando quiescenti homini involuntariisillis et alternis motibus agitantur membra, palpitationem (πἁλμον)dixit, posteriorem (_primam_) vero, quæ non fit nisi homo coneturpartes 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 markthose morbid motions which chiefly characterise this disease, notwithstanding that this term has been anticipated by Sauvages, ascharacteristic of another species of tremor[7]. The separation ofpalpitation of the limbs (_Palmos_ of Galen, _Tremor Coactus_ of de laBoë) from tremor, is the more necessary to be insisted on, since thedistinction may assist in leading to a knowledge of the seat of thedisease. It is also necessary to bear in mind, that this affection isdistinguishable from tremor, by the agitation, in the former, occurring whilst the affected part is supported and unemployed, andbeing even checked by the adoption of voluntary motion; whilst in thelatter, the tremor is induced immediately on bringing the parts intoaction. Thus an artist, afflicted with the malady here treated of, whilst his hand and arm is palpitating strongly, will seize hispencil, and the motions will be suspended, allowing him to use it fora short period; but in tremor, if the hand be quite free from theaffection, should the pen or pencil be taken up, the tremblingimmediately 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 awalking to a running pace. _ This affection, which observation seems to authorise the beingconsidered as a symptom peculiar to this disease, has been mentionedby few nosologists: it appears to have been first noticed by Gaubius, who says, “Cases occur in which the muscles duly excited into actionby the impulse of the will, do then, with an unbidden agility, andwith an impetus not to be repressed, accelerate their motion, and runbefore the unwilling mind. It is a frequent fault of the musclesbelonging to speech, nor yet of these alone: I have seen one, who wasable 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 hasbeen very rarely seen by authors, appears to be referable to the samegenus (Scelotyrbe, of which he makes _Chorea sancti viti_ the firstspecies); which, he says, “I think cannot be more fitly named thanhastening or hurrying Scelotyrbe (_Scelotyrbem festinantem, seufestiniam_). ” _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 theillustrious Gaubius; a similar affection of the speech, when thetongue thus outruns the mind, is termed volubility. Mons. De Sauvagesattributes this complaint to a want of flexibility in the muscularfibres. Hence, he supposes, that the patients make shorter steps, andstrive with a more than common exertion or impetus to overcome theresistance; walking with a quick and hastened step, as if hurriedalong against their will. _Chorea Viti_, he says, attacks the youthof both sexes, but this disease only those advanced in years; andadds, that it has hitherto happened to him to have seen only two ofthese cases; and that he has nothing to offer respecting them, eitherin 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 _Scelotyrbefestinans_ of the latter nosologist, which appear to be characteristicsymptoms of this disease, it becomes necessary, in the next place, toendeavour to distinguish this disease from others which may bear aresemblance 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, someof which do not appear to have yet engaged the general notice of theprofession, particular care is required whilst endeavouring to markits diagnostic characters. It is sufficient, in general, to point outthe characteristic differences which are observable between diseasesin some respects resembling each other. But in this case more isrequired: it is necessary to show that it is a disease which does notaccord with any which are marked in the systematic arrangements ofnosologists; and that the name by which it is here distinguished hasbeen hitherto vaguely applied to diseases very different from eachother, as well as from that to which it is now appropriated. Palsy, either consequent to compression of the brain, or dependent onpartial exhaustion of the energy of that organ, may, when the palsiedlimbs become affected with tremulous motions, be confounded with thisdisease. In those cases the abolition or diminution of voluntarymuscular action takes place suddenly, the sense of feeling beingsometimes also impaired. But in this disease, the diminution of theinfluence of the will on the muscles comes on with extreme slowness, is always accompanied, and even preceded, by agitations of theaffected parts, and never by a lessened sense of feeling. The dictatesof the will are even, in the last stages of the disease, conveyed tothe muscles; and the muscles act on this impulse, but their actionsare perverted. Anomalous cases of convulsive affections have been designated by theterm Shaking Palsy: a term which appears to be improperly applied tothese cases, independent of the want of accordance between them andthat 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 sanguineousand robust constitution, had an involuntary motion of her right arm, occasioned by a fright, which first brought on convulsion fits, andmost excruciating pain in the stomach, which vanished on a sudden, andher right arm was instantaneously flung into an involuntary andperpetual motion, like the swing of a pendulum, raising the hand, atevery vibration higher than her head; but if by any means whatever itwas stopped; the pain in her stomach came on again, and convulsionfits were the certain consequence, which went off when the vibrationof her hand returned. ” Another case, which the Doctor designates as 'A Shaking Palsy, 'apparently from worms, he describes thus, “A poor boy, about twelveor thirteen years of age, was seized with a Shaking Palsy. His legsbecame useless, and together with his head and hands, were incontinual agitation; after many weeks trial of various remedies, myassistance was desired. “His bowels being cleared, I ordered him a grain of Opium a day in thegum pill; and in three or four days the shaking had nearly left him. ”By pursuing this plan, the medicine proving a vermifuge, he could soonwalk, and was restored to perfect health. Whether these cases should be classed under Shaking Palsy or not, isnecessary to be here determined; since, if they are properly ranked, the cases which have been described in the preceding pages, differ somuch from them as certainly to oppose their being classed together:and the disease, which is the subject of these pages, cannot beconsidered as the same with Shaking Palsy, as characterised by thosecases. The term Shaking Palsy is evidently inapplicable to the first of thesecases, 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 ofdisease, generated by a disordered state of primæ viæ, sympatheticallyaffecting the nervous influence in a distant part of the body. Unless attention is paid to one circumstance, this disease will beconfounded with those species of passive tremblings to which the termShaking Palsies has frequently been applied. These are, _tremortemulentus_, the trembling consequent to indulgence in the drinking ofspirituous liquors; that which proceeds from the immoderate employmentof tea and coffee; that which appears to be dependent on advanced age;and all those tremblings which proceed from the various circumstanceswhich induce a diminution of power in the nervous system. But byattending to that circumstance alone, which has been already noted ascharacteristic of mere tremor, the distinction will readily be made. If the trembling limb be supported, and none of its muscles be calledinto action, the trembling will cease. In the real Shaking Palsy thereverse of this takes place, the agitation continues in full forcewhilst the limb is at rest and unemployed; and even is sometimesdiminished 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 thisdisease, it is necessary to plead, that it is made under veryunfavourable circumstances. Unaided by previous inquiries immediatelydirected to this disease, and not having had the advantage, in asingle case, of that light which anatomical examination yields, opinions and not facts can only be offered. Conjecture founded onanalogy, and an attentive consideration of the peculiar symptoms ofthe disease, have been the only guides that could be obtained for thisresearch, the result of which is, as it ought to be, offered withhesitation. 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 dependson some irregularity in the direction of the nervous influence; by thewide range of parts which are affected, that the injury is rather inthe source of this influence than merely in the nerves of the parts;by the situation of the parts whose actions are impaired, and theorder in which they become affected, that the proximate cause of thedisease is in the superior part of the medulla spinalis; and by theabsence of any injury to the senses and to the intellect, that themorbid state does not extend to the encephalon. Uncertainty existing as to the nature of the proximate cause of thisdisease, its remote causes must necessarily be referred to withindecision. Assuming however the state just mentioned as the proximatecause, it may be concluded that this may be the result of injuries ofthe medulla itself, or of the theca helping to form the canal in whichit is inclosed. The great degree of mobility in that portion of the spine which isformed by the superior cervical vertebræ, must render it, and thecontained parts, liable to injury from sudden distortions. Hencetherefore may proceed inflammation of quicker or of slower progress, disease of the vertebræ, derangement of structure in the medulla, orin its membranes, thickening or even ulceration of the theca, effusionof fluids, &c. But in no case which has been noticed, has the patient recollectedreceiving any injury of this kind, or any fixed pain in early life inthese parts, which might have led to the opinion that the foundationfor this malady had been thus laid. On the subject indeed of remotecauses, no satisfactory accounts has yet been obtained from any of thesufferers. Whilst one has attributed this affliction to indulgence inspirituous liquors, and another to long lying on the damp ground; theothers have been unable to suggest any circumstance whatever, which, in their opinion, could be considered as having given origin, ordisposed, to the calamity under which they suffered. Cases illustrative of the nature and cause of this malady are veryrare. In the following case symptoms very similar are observable, sofar as affecting the lower extremities. That the medulla spinalis washere affected, and in its lower part, is not to be doubted: but this, unfortunately, was never ascertained by examination. It must behowever remarked, that this case differed from those which have beengiven of this disease, in the suddenness with which the symptomsappeared. _A. B. _ aged twenty-six years, during a course of mercury for avenereal affection, was exposed to severely inclement weather, forseveral hours, and the next morning, complained of extreme pain in theback, and of total inability to employ voluntarily the muscles of thelower extremities, which were continually agitated with severeconvulsive motions. The physician who attended him employed thosemeans which seemed best calculated to relieve him; but with nobeneficial effect. The lower extremities were perpetually agitatedwith strong palpitatory motions, and, frequently, three or four timesin a minute, suddenly raised with great vehemence two or three feetfrom the ground, either in a forward or oblique direction, strikingone limb against the other, or against the chairs, tables, or anysubstance which stood in the way. To check these inordinate motions, no means were in the least effectual, except striking the thighsforcibly during the more violent convulsions. No advantage was derivedfrom all the means which were employed during upwards of twelvemonths. Full ten years after this period, the unhappy subject of this maladywas casually met in the street, shifting himself along, seated in achair; the convulsive motions having ceased, and the limbs havingbecome totally inert, and insensible to any impulse of the will. It must be acknowledged, that in the well-known cases, described byMr. Potts, of that kind of Palsy of the lower limbs which isfrequently found to accompany a curvature of the spine, and in which acarious state of the vertebræ is found to exist, no instructiveanalogy is discoverable; slight convulsive motions may indeed happenin the disease proceeding from curvature of the spine; but palpitatingmotions of the limbs, such as belong to the disease here described, donot appear to have been hitherto noticed. Whilst striving to determine the nature and origin of this disease, itbecomes necessary to give the following particulars of an interestingcase of Palsy occasioned by a fall, attended with uncommon symptoms, related by Dr. Maty, in the third volume of the Medical Observationsand Inquiries. The subject of this case, the Count de Lordat, had themisfortune to be overturned from a pretty high and steep bank. Hishead pitched against the top of the coach, and was bent from left toright; his left shoulder, arm, and especially his hand, wereconsiderably bruised. At first he felt a good deal of pain along theleft side of his neck, but neither then, nor at any other time, had heany faintings, vomitings, or giddiness. —On the sixth day he was letblood, on account of the pain in his shoulder and the contusion of hishand, which were then the only symptoms he complained of, and ofwhich he soon found himself relieved. —Towards the beginning of thefollowing winter, he began to find _a small impediment in utteringsome words, and his left arm appeared weaker_. In the followingspring, having suffered considerably from the severities of the wintercampaign, he found _the difficulty in speaking, and in moving his leftarm, considerably increased_. —On employing the thermal waters ofBourbonne, his speech become freer, but, on his return to Paris, thePalsy was increased, and the arm somewhat wasted. —In the beginning ofthe next spring he went to Balaruc; when he became affected with_involuntary convulsive motions all over the body_. The left armwithered more and more, _a spitting began_, and now it was _withdifficulty that he uttered a few words_. Frictions and sinapisms weresuccessively tried, and an issue, made by a caustic, was kept open forsome time without any effect; but no mention is made of what part theissue was established in. Soon after this, and three years and a half after the fall, DoctorMaty first saw the patient, and gives the following description ofhis situation. “A more melancholy object I never beheld. The patient, naturally a handsome, middle-sized, sanguine man, of a cheerfuldisposition, and an active mind, appeared much emaciated, stooping, and dejected. _He still walked alone with a cane, from one room to theother, but with great difficulty, and in a tottering manner_; his lefthand and arm were much reduced, and would hardly perform any motion;_the right was somewhat benumbed, and he could scarcely lift it up tohis head; his saliva was continually trickling out of his mouth, andhe had neither the power of retaining it, nor of spitting it outfreely_. What words he still could utter were monosyllables, and thesecame out, after much struggle, in a violent expiration, and with sucha low voice and indistinct articulation, as hardly to be understoodbut by those who were constantly with him. He fetched his breathrather hard; his pulse was low, but neither accelerated norintermitting. He took very little nourishment, could chew and swallowno solids, and even found great pain in getting down liquids. Milk wasalmost his only food; his body was rather loose, his urine natural, his sleep good, his senses, and the powers of his mind, unimpaired; hewas attentive to, and sensible of every thing which was said inconversation, and shewed himself very desirous of joining in it; butwas continually checked by the impediment in his speech, and thedifficulty which his hearers were put to. Happily for him he was ableto read, and as capable as ever of writing, as he shewed me, byputting into my hands an account of his present situation, drawn up byhimself: and I am informed that he spent his time to the very last, inwriting upon some of the most abstruse subjects. ” This gentleman died about four years after the accident, when the bodywas examined by Dr. Bellett and Mons. Sorbier, who made the followingreport: “We first examined the muscles of the tongue, which were foundextenuated and of a loose texture. We observed no signs of compressionin the lingual and brachial nerves, as high as their exit from thebasis of the cranium and the vertebræ of the neck; but they appearedto us more compact than they commonly are, being nearly tendinous. Thedura mater was in a sound state, but the pia mater was full of bloodand lymph; on it several hydatids, and towards the falx some marks ofsuppuration were observed. The ventricles were filled with water, andthe plexus choroides was considerably enlarged, and stuffed withgrumous blood. The cortical surface of the brain appeared much brownerthan usual, but neither the medullary part nor cerebellum wereimpaired. We chiefly took notice of the Medulla Oblongata, this wasgreatly enlarged, surpassing the usual size by more than one third. Itwas likewise more compact. The membranes, which, in theircontinuation, inclose the spinal marrow, were so tough that we foundgreat difficulty in cutting through them, and we observed this to bethe cause of the tendinous texture of the cervical nerves. The marrowitself had acquired such solidity as to elude the pressure of ourfingers, it resisted as a callous body, and could not be bruised. Thishardness was observed all along the vertebræ of the neck, but lessenedby degrees, and was not near so considerable in the vertebræ of thethorax. Though the patient was but nine and thirty years old, thecartilages of the sternum were ossified, and required as much labourto cut them asunder as the ribs; like these they were spungy, butsomewhat whiter. The lungs and heart were sound. At the bottom of thestomach appeared an inflammation, which increased as it extended tothe intestines. The ileum looked of that dark and livid hue, which isobserved in membranous parts tending to mortification. The colon wasnot above an inch in diameter, the rectum was smaller still, but bothappeared sound. —From these appearances, we were at no loss to fix thecause of this gradual palsy in the alteration of the medulla spinalisand oblongata. ” Dr. Bellett offers the following explanation of these changes. “Iconceive, that, by this accident, the head being violently bent to theright, the nervous membranes on the left were excessively stretchedand irritated; that this cause extended by degrees to the spinalmarrow, which being thereby compressed, brought on the paralyticsymptoms, not only of the left arm, but at last in some measure alsoof the right. This induration seems to have been occasioned by theconstant afflux of the nutritive juices, which were stopt at thatplace, and deprived of their most liquid parts; the grosser ones beingunable to spread in the boney cavity, by which they were confined, could only acquire a greater solidity, and change a soft body into ahard and nearly osseous mass. This likewise accounts for the increaseof the medulla oblongata, which being loaded with more juices than itcould 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 themis stopt in its progress. The medulla oblongata not growing so hard asthe spinalis, was doubtless owing to its not being confined in anosseous theca, but surrounded with soft parts, which allowed it roomto spread. The obstruction from the bulk of this substance must haveaffected the brain, and probably induced the thickening of the piamater, the hydatids, and the beginning of suppuration, whereas thedura 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 isobservable between it and those cases which are mentioned in thebeginning of these pages. The weakened state of both arms; the powerfirst lessening in one arm, and then in a similar manner in the otherarm; the affection of the speech; the difficulty in chewing and inswallowing; as well as of retaining, or freely discharging, thespittle; the convulsive motions of the body; and the unimpaired stateof the intellects; constitute such a degree of accordance as, althoughit may not mark an identity of disease, serves at least to show thatnearly the same parts were the seat of the disease in both instances. Thus we attain something like confirmation of the supposed proximatecause, and of one of the assumed occasional causes. Whilst conjecturing as to the cause of this disease, the followingcollected observations on the effects of injury to the medullaspinalis, by Sir Everard Home, become particularly deserving ofattention. It thence appears, that none of the characteristic symptomsof this malady are produced by compression, laceration, or completedivision 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 functionsof the internal organs were carried on for thirty-five days, but theurine 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 thearms[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 theneck, there was a paralysis in all the parts below the laceration, thelining of the œsophagus was so sensible, that solids could not beswallowed, 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 wasmomentary loss of sight, loss of memory for fifteen minutes, andpermanent insensibility in all the lower parts of the body. The skinabove 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 hadpreviously existed; and in Case IV. The right arm, in which thepalpitation began, was said to have been very violently affected withrheumatic pain to the fingers ends. The consideration of this case, inwhich the palpitation had been preceded, at a considerable distance oftime, by this painful affection of the arm, led to the suppositionthat this latter circumstance might be the cause of the palpitations, and the other subsequent symptoms of this disease. This suppositionnaturally occasioned the attention to be eagerly fixed on thefollowing case; and of course influenced the mode of treatment whichwas adopted. _A. B. _ subject to rheumatic affection of the deltoid muscle, had feltthe usual inconveniences from it for two or three days; but at nightfound the pain had extended down the arm, along the inside of thefore-arm, and on the sides of the fingers, in which a continualtingling was felt. The pain, without being extremely intense, was suchas effectually to prevent sleep: and seemed to follow the course ofthe brachial nerve. Whilst ascertaining the propriety of thisconclusion, the pain was found to ramify, as it were, on the fore andback part of the chest; and was slightly augmented by drawing a deepbreath. 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 fromthe back part of the neck, by cupping; hot fomentations were appliedfor about the space of an hour, when the upper part of the back of theneck was covered with a blister, perspiration was freely induced bytwo or three small doses of antimonials, and the following morning thebowels were evacuated by an appropriate dose of calomel. On thefollowing day the pains were much diminished, and in the course offour or five days were quite removed. The arm and hand felt now morethan ordinarily heavy, and were evidently much weakened: aching, andfeeling extremely wearied after the least exertion. The strength ofthe arm was not completely recovered at the end of more thantwelvemonths; and, after more than twice that time, exertion wouldexcite the feeling of painful weariness, but no palpitation or otherunpleasant symptom has occurred during the five or six years whichhave since passed. The commencement, progress, and termination of this attack; with thesuccess attending the mode of treatment, and the symptoms whichfollowed, seem to lead to the conjecture, that the proximate cause ofthe disease, in this case, existed in the medulla spinalis, and thatit might, if neglected, have gradually resolved itself into thatdisease which is the object of our present inquiry. Some few months after the occurrence of the preceding case, the writerof these lines was called to a female about forty years of age, complaining of great pain in both the arms, extending from theshoulder to the finger ends. She stated, that she was attacked in thesame manner as is described in the preceding case, about nine monthsbefore; that the complaint was considered as rheumatism, and was notbenefited by any of the medicines which had been employed; but thatafter three or four weeks it gradually amended, leaving both the armsand hands in a very weakened and trembling state. From this state theywere now somewhat recovered; but she was extremely anxious, fearingthat if the present attack should not be soon checked, she mightentirely 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 forsometime to yield a purulent discharge, were applied over the cervicalvertebræ; and in the course of a very few days the pain was entirelyremoved. It is regretted that no farther information, as to theprogress of this case, could be obtained. On meeting with these two cases, it was thought that it might not beimprobable that attacks of this kind, considered at the time merely asrheumatic affections, might lay the foundation of this lamentabledisease, which might manifest itself at some distant period, when thecircumstance in which it had originated, had, perhaps, almost escapedthe memory. Indeed when it is considered that neither in the ordinarycases of Palsy of the lower extremities, proceeding from diseasedspine, nor in cases of injured medulla from fractured vertebræ, any ofthe peculiar symptoms of this disease are observable, we necessarilydoubt as to the probability of its being the direct effect of anysudden 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 itsorigin to any more obvious cause, we are led to seek for it in someslow morbid change in the structure of the medulla, or its investingmembranes, or theca, occasioned by simple inflammation, or rheumaticor scrophulous affection. It must be too obvious that the evidence adduced as to the nature ofthe proximate and occasional causes of this disease, is by no meansconclusive. A reference to the test therefore which will be yielded byan examination of some of the more prominent symptoms, especially asto their agreement with the supposed proximate cause, is moreparticularly demanded. Satisfied as to the importance of this part ofthe present undertaking, no apology is offered for the extent to whichthe examination is carried on. If the palpitation and the attendant weakness of the limbs, &c. Beconsidered as to the order in which the several parts are attacked, itis believed, that some confirmation will be obtained of the opinionwhich has been just offered, respecting the cause, or at least theseat, of that change which may be considered as the proximate cause ofthis disease. One of the arms, in all the cases which have been here mentioned, hasbeen the part in which these symptoms have been first noticed; thelegs, head, and trunk have then become gradually affected, and lastly, the muscles of the mouth and fauces have yielded to the morbidinfluence. The arms, the parts first manifesting disordered action, of coursedirect us, whilst searching for the cause of these changes, to thebrachial nerves. But finding the mischief extending to other parts, not supplied with these, but with other nerves derived from nearly thesame part of the medulla spinalis, we are of course led to considerthat portion of the medulla spinalis itself, from which these nervesare 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 thefailure of power in the muscles of the trunk, such a change in thesubstance of the medulla spinalis may be inferred, as shall haveconsiderably interrupted, and interfered with, the extension of thenervous influence to those parts, whose nerves are derived from anyportion of the medulla below the part which has undergone the diseasedchange. The difficulty in supporting the trunk erect, as well as thepropensity to the adopting of a hurried pace, is also referable tosuch a diminution of the nervous power in the extensor muscles of thehead and trunk, as prevents them from performing the offices ofmaintaining the head and body in an erect position. From the impediment to speech, the difficulty in mastication andswallowing, the inability to retain, or freely to eject, the Saliva, may with propriety be inferred an extension of the morbid changeupwards through the medulla spinalis to the medulla oblongata, necessarily impairing the powers of the several nerves derived fromthat portion into which the morbid change may have reached. In thelate occurrence of this set of symptoms, and the extension upwards ofthe diseased state, a very close agreement is observable between thisdisease and that which has been already shown, proved fatal to theCount de Lordat. But in this case, the disease doubtlessly becamedifferently modified, and its symptoms considerably accelerated, inconsequence of the magnitude of the injury by which the disease wasinduced. CHAP. V. CONSIDERATIONS RESPECTING THE MEANS OF CURE. The inquiries made in the preceding pages yield, it is to be muchregretted, but little more than evidence of inference: nothing directand satisfactory has been obtained. All that has been ventured toassume here, has been that the disease depends on a disordered stateof that part of the medulla which is contained in the cervicalvertebræ. But of what nature that morbid change is; and whetheroriginating in the medulla itself, in its membranes, or in thecontaining theca, is, at present, the subject of doubt and conjecture. But although, at present, uninformed as to the precise nature of thedisease, still it ought not to be considered as one against whichthere exists no countervailing remedy. On the contrary, there appears to be sufficient reason for hoping thatsome remedial process may ere long be discovered, by which, at least, the progress of the disease may be stopped. It seldom happens thatthe agitation extends beyond the arms within the first two years;which period, therefore, if we were disposed to divide the diseaseinto stages, might be said to comprise the first stage. In thisperiod, it is very probable, that remedial means might be employedwith success: and even, if unfortunately deferred to a later period, they might then arrest the farther progress of the disease, althoughthe removing of the effects already produced, might be hardly to beexpected. From a review of the changes which had taken place in the case ofCount de Lordat, it seems as if we were able to trace the order andmode in which the morbid changes may proceed in this disease. From anyoccasional cause, the thecal ligament, the membranes, or the medullaitself, may pass into the state of simple excitement or irritation, which may be gradually succeeded by such a local afflux anddetermination of blood into the minute vessels, as may terminate inactual but slow inflammation. The result of this would be athickening of the theca, or membranes, and perhaps an increase in thevolume of the medulla itself, which would gradually occasion such adegree of pressure against the sides of the unyielding canal, as musteventually intercept the influence of the brain upon the inferiorportion of the medullary column, and upon the parts on which thenerves of this portion are disposed. From this review, and assuming that the morbid changes in this diseasemay not be widely dissimilar from those which occurred in the case ofCount de Lordat, the chance of relief from the proposed mode oftreatment may appear to be sufficient to warrant its trial. In such a case then, at whatever period of the disease it might beproposed to attempt the cure, blood should be first taken from theupper part of the neck, unless contra-i(n)dicated by any particul(ar)circumstance. After which vesicatories should be applied to the (sa)mepart, and a purulent discharge obtained by appropriate use of theSabine Liniment; having recourse to the application of a freshblister, when from the diminution of the discharging surface, pus isnot secreted in a sufficient quantity. Should the blisters be foundtoo inconvenient, or a sufficient quantity of discharge not beobtained thereby, an issue of at least an inch and a half in lengthmight be established on each side of the vertebral columna, in itssuperior part. These, it is presumed, would be best formed withcaustic, 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 incases of Palsy of the lower extremities from diseased spine? althoughsatisfied with ascribing those cases to scrofulous action, we are infact as little informed respecting the nature of the affection, inducing the carious state of the vertebræ, as we are respecting thepeculiar change of structure which takes place in this disease. Equally uninformed are we also as to the peculiar kind of morbidaction, which takes place in the ligaments of the joints; as well asthat which takes place in different instances of deep seated pains andaffections of the parts contained in the head, thorax, and abdomen, and in all which cases the inducing of a purulent discharge in theirneighbourhood is so frequently productive of a cure. Experiment hasnot indeed been yet employed to prove, but analogy certainly warrantsthe hope, that similar advantages might be derived from the use of themeans enumerated, in the present disease. It is obvious, that thechance of obtaining relief will depend in a great measure on theperiod at which the means are employed. As in every other disease, sohere, the earlier the remedies are resorted to, the greater will bethe probability of success. But in this disease there is onecircumstance which demands particular attention; the long period towhich it may be extended. One of its peculiar symptoms, Scelotyrbefestinans, may not occur until the disease has existed ten or twelveyears, or more; hence, when looking for the period, within which ourhopes of remedial aid is to be limited; we may, guided by the slowprogress of the malady, extend it to a great length, when comparedwith that within which we should be obliged to confine ourselves inmost other diseases. But it is much to be apprehended, as in many other cases, that theresolution of the patients will seldom be sufficient to enable them topersevere through the length of time which the proposed process willnecessarily require. As slow as is the progress of the disease, soslow in all probability must be the period of the return to health. Inmost cases, especially in those in which the disease has been allowedto exist long unopposed, it may be found that all that art is capableof accomplishing, is that of checking its further progress. Nor willthis be regarded as a trifle, when, by reference to the history of thedisease, is seen the train of harassing evils which would be thusavoided. But it seems as if there existed reason for hoping for more. Forsupposing change of structure to have taken place, it is extremelyprobable that this change may be merely increase in mass or volume byinterstitial addition, the consequence of increased action in theminute vessels of the part. In that case, should the instituting of apurulent discharge, in a neighbouring part, act in the manner which wewould presume it may—should it by keeping up a constant discharge, not merely alter the determination, but diminish the inordinate actionof the vessels in the diseased part; and at the same time excite theabsorbents to such increased action as may remove the added matter;there will exist strong ground for hope, that a happy, though slowrestoration to health, may be obtained. Until we are better informed respecting the nature of this disease, the employment of internal medicines is scarcely warrantable; unlessanalogy should point out some remedy the trial of which rational hopemight authorize. Particular circumstances indeed must arise indifferent cases, in which the aid of medicine may be demanded: and theintelligent will never fail to avail themselves of any opportunity ofmaking trial of the influence of mercury, which has in so manyinstances, manifested its power in correcting derangement ofstructure. The weakened powers of the muscles in the affected parts is soprominent a symptom, as to be very liable to mislead the inattentive, who may regard the disease as a mere consequence of constitutionaldebility. If this notion be pursued, and tonic medicines, and highlynutritious diet be directed, no benefit is likely to be thus obtained;since the disease depends not on general weakness, but merely on theinterruption of the flow of the nervous influence to the affectedparts. It is indeed much to be regretted that this malady is generallyregarded by the sufferers in this point of view, so discouraging tothe employment of remedial means. Seldom occurring before the age offifty, and frequently yielding but little inconvenience for severalmonths, it is generally considered as the irremediable diminution ofthe nervous influence, naturally resulting from declining life; andremedies therefore are seldom sought for. Although unable to trace the connection by which a disordered state ofthe stomach and bowels may induce a morbid action in a part of themedulla spinalis, yet taught by the instruction of Mr. Abernethy, little hesitation need be employed before we determine on theprobability of such occurrence. The power, possessed by sympathy, ofinducing such disordered action in a distant part, and the probabilityof such disordered action producing derangement of structure, canhardly be denied. The following Case seems to prove, at least, thatthe mysterious sympathetic influence which so closely simulates theforms of other diseases, may induce such symptoms as would seem tomenace the formation of a disease not unlike to that which we havebeen here treating of. _A. B. _ A man, 54 years of age, of temperate habits and regular stateof bowels, became gradually affected with slight numbness andprickling, with a feeling of weakness in both arms, accompanied by asense of fulness about the shoulders, as if produced by the pressureof a strong ligature; and at times a slight trembling of the hands. During the night, the fullness, numbness, and prickling were muchincreased. The appetite had been diminished for several weeks; and theabdomen, on being examined, felt as though containing considerableaccumulation. Before adopting any other measures, and as there appeared to be nomarks of vascular fulness, it was determined to empty the bowels. Thiswas done effectually by moderate doses of calomel, with the occasionalhelp of Epsom salts; and in about ten days, by these means alone, thecomplaints 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, theleading of the attention of those who humanely employ anatomicalexamination in detecting the causes and nature of diseases, particularly to this malady. By their benevolent labours its realnature may be ascertained, and appropriate modes of relief, or even ofcure, pointed out. To such researches the healing art is already much indebted for theenlargement of its powers of lessening the evils of sufferinghumanity. Little is the public aware of the obligations it owes tothose who, led by professional ardour, and the dictates of duty, havedevoted themselves to these pursuits, under circumstances mostunpleasant and forbidding. Every person of consideration and feeling, may judge of the advantages yielded by the philanthropic exertions ofa HOWARD; but how few can estimate the benefits bestowed on mankind, by the labours of a MORGAGNI, HUNTER, or BAILLIE. FINIS.