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[ii]
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[iii]
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[iv]
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.

AN
ESSAY
ON THE
SHAKING PALSY.

CHAPTER I.[1]

DEFINITION—HISTORY—ILLUSTRATIVE CASES.

SHAKING PALSY. (Paralysis Agitans.)

The term Shaking Palsy has been vaguely
employed by medical writers in general.
By some it has been used to designate ordinary[2]
cases of Palsy, in which some slight
tremblings have occurred; whilst by others
it has been applied to certain anomalous affections,
not belonging to Palsy.

The shaking of the limbs belonging to this
disease was particularly noticed, as will be
seen when treating of the symptoms, by
Galen, who marked its peculiar character
by an appropriate term. The same symptom,
it will also be seen, was accurately
treated of by Sylvius de la Boë. Juncker
also seems to have referred to this symptom:
having divided tremor into active and
passive, he says of the latter, “ad affectus
semiparalyticos pertinent; de qualibus hic
agimus, quique tremores paralytoidei vocantur.”
Tremor has been adopted, as a genus,
by almost every nosologist; but always unmarked,
in their several definitions, by such
characters as would embrace this disease.
The celebrated Cullen, with his accustomed
accuracy observes, “Tremorem, utpote semper
symptomaticum, in numerum generum
recipere nollem; species autem a Sauvagesio
recensitas, prout mihi vel astheniæ vel paralysios,
vel convulsionis symptomata esse[3]
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.

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
[4]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[5]
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[6]
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[7]
time, irresistibly impelled to take much
quicker and shorter steps, and thereby to
adopt unwillingly a running pace. In
some cases it is found necessary entirely to
substitute running for walking; since otherwise
the patient, on proceeding only a very
few paces, would inevitably fall.

In this stage, the sleep becomes much
disturbed. The tremulous motion of the
limbs occur during sleep, and augment
until they awaken the patient, and frequently
with much agitation and alarm.
The power of conveying the food to the
mouth is at length so much impeded that he
is obliged to consent to be fed by others.
The bowels, which had been all along torpid,
now, in most cases, demand stimulating
medicines of very considerable power: the
expulsion of the fæces from the rectum sometimes
requiring mechanical aid. As the disease
proceeds towards its last stage, the trunk
is almost permanently bowed, the muscular
power is more decidedly diminished, and
the tremulous agitation becomes violent.
The patient walks now with great difficulty,
and unable any longer to support himself[8]
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[9]
nature seizes a small portion of sleep, the
motion becomes so violent as not only to
shake the bed-hangings, but even the floor
and sashes of the room. The chin is now
almost immoveably bent down upon the
sternum. The slops with which he is attempted
to be fed, with the saliva, are continually
trickling from the mouth. The
power of articulation is lost. The urine
and fæces are passed involuntarily; and at
the last, constant sleepiness, with slight delirium,
and other marks of extreme exhaustion,
announce the wished-for release.

Case I.

Almost every circumstance noted in the
preceding description, was observed in a case
which occurred several years back, and
which, from the particular symptoms which
manifested themselves in its progress; from
the little knowledge of its nature, acknowledged
to be possessed by the physician who
attended; and from the mode of its termination;
excited an eager wish to acquire
some further knowledge of its nature and
cause.[10]

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[11]
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[12]
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.[13]

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[14]
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[15]
with lumbago, which was severe and lasted
some time. About eleven or twelve, or
perhaps more, years ago, he first perceived
weakness in the left hand and arm, and
soon after found the trembling commence.
In about three years afterwards the right
arm became affected in a similar manner:
and soon afterwards the convulsive motions
affected the whole body, and began to interrupt
the speech. In about three years
from that time the legs became affected.
Of late years the action of the bowels
had been very much retarded; and at
two or three different periods had, with
great difficulty, been made to yield to the
action of very strong cathartics. But
within the last twelvemonths this difficulty
has not been so great; perhaps owing to
an increased secretion of mucus, which envelopes
the passing fæces, and which precedes
and follows their discharge in considerable
quantity.

About a year since, on waking in the
night, he found that he had nearly lost the
use of the right side, and that the face was
much drawn to the left side. His medical[16]
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[17]
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[18]
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.[19]

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[20]
designation, as for assisting in forming probable
conjectures, as to the nature of the
malady, which it helps to characterise.
Tremors were distinguished by Juncker into
Active, those proceeding from sudden affection
of the minds, as terror, anger, &c. and
Passive, dependant on debilitating causes,
such as advanced age, palsy, &c[2]. But a
much more satisfactory and useful distinction
is made by Sylvius de la Boë into those
tremors which are produced by attempts at
voluntary motion, and those which occur
whilst the body is at rest[3]. Sauvages distinguishes
the latter of these species (Tremor
[21]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].

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
[22]distinxit, atque etiam diversis nominibus
insignivit, tremor enim (τϱὁμ &) facultatis
corpus moventis et vehentis infirmitate oboritur.
Quippe nemo, qui artus movere
non instituerit tremet. Palpitantes autem
partes, etiam in quiete fuerint, etiamsi nullum
illis motum induxeris palpitant. Ideo
primam (posteriorem) modo descriptam tremoris
speciem, quando quiescenti homini
involuntariis illis et alternis motibus agitantur
membra, palpitationem (πἁλμον) dixit,
posteriorem (primam) vero, quæ non fit
nisi homo conetur partes quasdam movere
tremorem vocavit.”

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
[23]separation of palpitation of the limbs (Palmos
of Galen, Tremor Coactus of de la Boë) from
tremor, is the more necessary to be insisted
on, since the distinction may assist in
leading to a knowledge of the seat of the
disease. It is also necessary to bear in mind,
that this affection is distinguishable from
tremor, by the agitation, in the former, occurring
whilst the affected part is supported
and unemployed, and being even checked
by the adoption of voluntary motion; whilst
in the latter, the tremor is induced immediately
on bringing the parts into action.
Thus an artist, afflicted with the malady
here treated of, whilst his hand and arm is
palpitating strongly, will seize his pencil,
and the motions will be suspended, allowing
[24]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.

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].”

[25]

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,
[26]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].

Having made the necessary inquiries respecting
these two affections, Tremor coactum
of Sylvius de la Boë and of Sauvages, and
Scelotyrbe festinans of the latter nosologist,
which appear to be characteristic symptoms
of this disease, it becomes necessary, in the
next place, to endeavour to distinguish this
disease from others which may bear a resemblance
to it in some particular respects.

CHAP. III.[27]

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[28]
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[29]
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[30]
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[31]
appears to have belonged more properly to
the genus Convulsio, of Cullen, or to Hieranosos
of Linnæus and Vogel[10].

The latter appears to be referable to that
class of proteal forms of disease, generated
by a disordered state of primæ viæ, sympathetically
[32]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.[33]

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.

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.[35]

The great degree of mobility in that portion
of the spine which is formed by the
superior cervical vertebræ, must render it,
and the contained parts, liable to injury from
sudden distortions. Hence therefore may
proceed inflammation of quicker or of slower
progress, disease of the vertebræ, derangement
of structure in the medulla, or in its
membranes, thickening or even ulceration
of the theca, effusion of fluids, &c.

But in no case which has been noticed,
has the patient recollected receiving any
injury of this kind, or any fixed pain in
early life in these parts, which might have
led to the opinion that the foundation for
this malady had been thus laid. On the
subject indeed of remote causes, no satisfactory
accounts has yet been obtained
from any of the sufferers. Whilst one has
attributed this affliction to indulgence in
spirituous liquors, and another to long lying
on the damp ground; the others have been
unable to suggest any circumstance whatever,
which, in their opinion, could be considered
as having given origin, or disposed,
to the calamity under which they suffered.[36]

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,[37]
three or four times in a minute, suddenly
raised with great vehemence two or three
feet from the ground, either in a forward
or oblique direction, striking one limb against
the other, or against the chairs, tables, or
any substance which stood in the way. To
check these inordinate motions, no means
were in the least effectual, except striking
the thighs forcibly during the more violent
convulsions. No advantage was derived from
all the means which were employed during
upwards of twelvemonths. Full ten years
after this period, the unhappy subject of
this malady was casually met in the street,
shifting himself along, seated in a chair; the
convulsive motions having ceased, and the
limbs having become totally inert, and insensible
to any impulse of the will.

It must be acknowledged, that in the
well-known cases, described by Mr. Potts,
of that kind of Palsy of the lower limbs
which is frequently found to accompany
a curvature of the spine, and in which
a carious state of the vertebræ is found
to exist, no instructive analogy is discoverable;
slight convulsive motions may indeed[38]
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[39]
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[40]
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[41]
natural, his sleep good, his senses, and the
powers of his mind, unimpaired; he was
attentive to, and sensible of every thing
which was said in conversation, and shewed
himself very desirous of joining in it; but
was continually checked by the impediment
in his speech, and the difficulty which his
hearers were put to. Happily for him he
was able to read, and as capable as ever of
writing, as he shewed me, by putting into
my hands an account of his present situation,
drawn up by himself: and I am informed
that he spent his time to the very
last, in writing upon some of the most abstruse
subjects.”

This gentleman died about four years
after the accident, when the body was examined
by Dr. Bellett and Mons. Sorbier, who
made the following report:

“We first examined the muscles of the
tongue, which were found extenuated and
of a loose texture. We observed no signs
of compression in the lingual and brachial
nerves, as high as their exit from the basis
of the cranium and the vertebræ of the neck;[42]
but they appeared to us more compact than
they commonly are, being nearly tendinous.
The dura mater was in a sound state, but
the pia mater was full of blood and lymph;
on it several hydatids, and towards the
falx some marks of suppuration were observed.
The ventricles were filled with
water, and the plexus choroides was considerably
enlarged, and stuffed with grumous
blood. The cortical surface of the brain
appeared much browner than usual, but
neither the medullary part nor cerebellum
were impaired. We chiefly took notice of
the Medulla Oblongata, this was greatly
enlarged, surpassing the usual size by more
than one third. It was likewise more compact.
The membranes, which, in their continuation,
inclose the spinal marrow, were
so tough that we found great difficulty
in cutting through them, and we observed
this to be the cause of the tendinous texture
of the cervical nerves. The marrow itself
had acquired such solidity as to elude the
pressure of our fingers, it resisted as a callous
body, and could not be bruised. This hardness
was observed all along the vertebræ
of the neck, but lessened by degrees, and[43]
was not near so considerable in the vertebræ
of the thorax. Though the patient
was but nine and thirty years old, the cartilages
of the sternum were ossified, and required
as much labour to cut them asunder
as the ribs; like these they were spungy,
but somewhat whiter. The lungs and heart
were sound. At the bottom of the stomach
appeared an inflammation, which increased
as it extended to the intestines. The ileum
looked of that dark and livid hue, which
is observed in membranous parts tending
to mortification. The colon was not above
an inch in diameter, the rectum was smaller
still, but both appeared sound.—From these
appearances, we were at no loss to fix the
cause of this gradual palsy in the alteration
of the medulla spinalis and oblongata.”

Dr. Bellett offers the following explanation
of these changes. “I conceive, that, by
this accident, the head being violently bent
to the right, the nervous membranes on
the left were excessively stretched and
irritated; that this cause extended by degrees
to the spinal marrow, which being[44]
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[45]
mater, being of a harder texture, was not
injured[11].”

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
[46]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].

“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].

[47]

“In a case where the substance of the medulla
was lacerated in the neck, there was
a paralysis in all the parts below the laceration,
the lining of the œsophagus was so
sensible, that solids could not be swallowed,
on account of the pain they occasioned[14].

“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.

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
[48]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[49]
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[50]
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[51]
it gradually amended, leaving both the arms
and hands in a very weakened and trembling
state. From this state they were now
somewhat recovered; but she was extremely
anxious, fearing that if the present attack
should not be soon checked, she might
entirely lose the use of her hands and arms.

Instructed by the preceding case, similar
means were here recommended. Leeches,
stimulating fomentations, and a blister,
which was made for sometime to yield a
purulent discharge, were applied over the
cervical vertebræ; and in the course of a
very few days the pain was entirely removed.
It is regretted that no farther information,
as to the progress of this case,
could be obtained.

On meeting with these two cases, it was
thought that it might not be improbable
that attacks of this kind, considered at the
time merely as rheumatic affections, might
lay the foundation of this lamentable disease,
which might manifest itself at some distant
period, when the circumstance in which it
had originated, had, perhaps, almost escaped[52]
the memory. Indeed when it is considered
that neither in the ordinary cases of Palsy
of the lower extremities, proceeding from
diseased spine, nor in cases of injured medulla
from fractured vertebræ, any of the
peculiar symptoms of this disease are observable,
we necessarily doubt as to the probability
of its being the direct effect of any
sudden injury. But taking all circumstances
into due consideration, particularly the very
gradual manner in which the disease commences,
and proceeds in its attacks; as well
as the inability to ascribe its origin to any
more obvious cause, we are led to seek for
it in some slow morbid change in the structure
of the medulla, or its investing membranes,
or theca, occasioned by simple inflammation,
or rheumatic or scrophulous
affection.

It must be too obvious that the evidence
adduced as to the nature of the proximate
and occasional causes of this disease, is by no
means conclusive. A reference to the test
therefore which will be yielded by an examination
of some of the more prominent
symptoms, especially as to their agreement[53]
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[54]
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[55]
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.[56]

CONSIDERATIONS RESPECTING THE MEANS
OF CURE.

The inquiries made in the preceding pages
yield, it is to be much regretted, but
little more than evidence of inference: nothing
direct and satisfactory has been obtained.
All that has been ventured to assume
here, has been that the disease depends
on a disordered state of that part of
the medulla which is contained in the cervical
vertebræ. But of what nature that
morbid change is; and whether originating
in the medulla itself, in its membranes, or
in the containing theca, is, at present, the
subject of doubt and conjecture. But although,
at present, uninformed as to the
precise nature of the disease, still it ought
not to be considered as one against which
there exists no countervailing remedy.

On the contrary, there appears to be sufficient
reason for hoping that some remedial
process may ere long be discovered, by which,
at least, the progress of the disease may be[57]
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[58]
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[59]
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].

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
[60]the carious state of the vertebræ, as
we are respecting the peculiar change of
structure which takes place in this disease.
Equally uninformed are we also as to the
peculiar kind of morbid action, which takes
place in the ligaments of the joints; as well
as that which takes place in different instances
of deep seated pains and affections
of the parts contained in the head, thorax,
and abdomen, and in all which cases the
inducing of a purulent discharge in their
neighbourhood is so frequently productive of
a cure. Experiment has not indeed been yet
employed to prove, but analogy certainly
warrants the hope, that similar advantages
might be derived from the use of the means
enumerated, in the present disease. It is
obvious, that the chance of obtaining relief
will depend in a great measure on the period
at which the means are employed. As
in every other disease, so here, the earlier
the remedies are resorted to, the greater will
be the probability of success. But in this
disease there is one circumstance which demands
particular attention; the long period
to which it may be extended. One of its
peculiar symptoms, Scelotyrbe festinans,[61]
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.[62]

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[63]
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[64]
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[65]
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[66]
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.