Part 4

Another case, which the Doctor designates as 'A Shaking Palsy,' apparently from worms, he describes thus, "A poor boy, about twelve or thirteen years of age, was seized with a Shaking Palsy. His legs became useless, and together with his head and hands, were in continual agitation; after many weeks trial of various remedies, my assistance was desired.

"His bowels being cleared, I ordered him a grain of Opium a day in the gum pill; and in three or four days the shaking had nearly left him." By pursuing this plan, the medicine proving a vermifuge, he could soon walk, and was restored to perfect health.

Whether these cases should be classed under Shaking Palsy or not, is necessary to be here determined; since, if they are properly ranked, the cases which have been described in the preceding pages, differ so much from them as certainly to oppose their being classed together: and the disease, which is the subject of these pages, cannot be considered as the same with Shaking Palsy, as characterised by those cases.

The term Shaking Palsy is evidently inapplicable to the first of these cases, which appears to have belonged more properly to the genus Convulsio, of Cullen, or to Hieranosos of Linnaeus and Vogel.

Agitatio corporis vel artuum convulsiva continua, chronica, cum integritate sensuum.--Vogel.

This genus is resolved by Cullen into that of Convulsio. Synops. Nosol. 1803.

Dr. Macbride has given a very interesting and illustrative case of this disease.

"Hieranasos, or Morbus Sacer, so called, as being vulgarly supposed to arise from witchcraft, or some extraordinary celestial influence, is a distinct genus of disease, though a very uncommon one; the author once had an opportunity of seeing a case. The patient was a lad about seventeen, who at that time had laboured under this extraordinary disease for more than twelve years. His body was so distorted, and the legs and arms so twisted round it, by the continued convulsive working, that no words can give an adequate idea of the oddity of his figure; the agitation of the muscles was perpetual; but in general he did not complain of pain nor sickness; and had his senses perfectly, insomuch that he used to assist his mother, who kept a little school, in teaching children to read." A methodical Introduction to the Theory and Practice of Physic. By David Macbride, M.D. p. 559.]

The latter appears to be referable to that class of proteal forms of disease, generated by a disordered state of primae viae, sympathetically affecting the nervous influence in a distant part of the body.

Unless attention is paid to one circumstance, this disease will be confounded with those species of passive tremblings to which the term Shaking Palsies has frequently been applied. These are, tremor temulentus, the trembling consequent to indulgence in the drinking of spirituous liquors; that which proceeds from the immoderate employment of tea and coffee; that which appears to be dependent on advanced age; and all those tremblings which proceed from the various circumstances which induce a diminution of power in the nervous system. But by attending to that circumstance alone, which has been already noted as characteristic of mere tremor, the distinction will readily be made. If the trembling limb be supported, and none of its muscles be called into action, the trembling will cease. In the real Shaking Palsy the reverse of this takes place, the agitation continues in full force whilst the limb is at rest and unemployed; and even is sometimes diminished by calling the muscles into employment.

CHAP. IV.

PROXIMATE CAUSE--REMOTE CAUSES--ILLUSTRATIVE CASES.

Before making the attempt to point out the nature and cause of this disease, it is necessary to plead, that it is made under very unfavourable circumstances. Unaided by previous inquiries immediately directed to this disease, and not having had the advantage, in a single case, of that light which anatomical examination yields, opinions and not facts can only be offered. Conjecture founded on analogy, and an attentive consideration of the peculiar symptoms of the disease, have been the only guides that could be obtained for this research, the result of which is, as it ought to be, offered with hesitation.

SUPPOSED PROXIMATE CAUSE.

A diseased state of the medulla spinalis, in that part which is contained in the canal, formed by the superior cervical vertebrae, and extending, as the disease proceeds, to the medulla oblongata.

By the nature of the symptoms we are taught, that the disease depends on some irregularity in the direction of the nervous influence; by the wide range of parts which are affected, that the injury is rather in the source of this influence than merely in the nerves of the parts; by the situation of the parts whose actions are impaired, and the order in which they become affected, that the proximate cause of the disease is in the superior part of the medulla spinalis; and by the absence of any injury to the senses and to the intellect, that the morbid state does not extend to the encephalon.

Uncertainty existing as to the nature of the proximate cause of this disease, its remote causes must necessarily be referred to with indecision. Assuming however the state just mentioned as the proximate cause, it may be concluded that this may be the result of injuries of the medulla itself, or of the theca helping to form the canal in which it is inclosed.

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

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

Cases illustrative of the nature and cause of this malady are very rare. In the following case symptoms very similar are observable, so far as affecting the lower extremities. That the medulla spinalis was here affected, and in its lower part, is not to be doubted: but this, unfortunately, was never ascertained by examination. It must be however remarked, that this case differed from those which have been given of this disease, in the suddenness with which the symptoms appeared.

A. B. aged twenty-six years, during a course of mercury for a venereal affection, was exposed to severely inclement weather, for several hours, and the next morning, complained of extreme pain in the back, and of total inability to employ voluntarily the muscles of the lower extremities, which were continually agitated with severe convulsive motions. The physician who attended him employed those means which seemed best calculated to relieve him; but with no beneficial effect. The lower extremities were perpetually agitated with strong palpitatory motions, and, frequently, three or four times in a minute, suddenly raised with great vehemence two or three feet from the ground, either in a forward or oblique direction, striking one limb against the other, or against the chairs, tables, or any substance which stood in the way. To check these inordinate motions, no means were in the least effectual, except striking the thighs forcibly during the more violent convulsions. No advantage was derived from all the means which were employed during upwards of twelvemonths. Full ten years after this period, the unhappy subject of this malady was casually met in the street, shifting himself along, seated in a chair; the convulsive motions having ceased, and the limbs having become totally inert, and insensible to any impulse of the will.

It must be acknowledged, that in the well-known cases, described by Mr. Potts, of that kind of Palsy of the lower limbs which is frequently found to accompany a curvature of the spine, and in which a carious state of the vertebrae is found to exist, no instructive analogy is discoverable; slight convulsive motions may indeed happen in the disease proceeding from curvature of the spine; but palpitating motions of the limbs, such as belong to the disease here described, do not appear to have been hitherto noticed.

Whilst striving to determine the nature and origin of this disease, it becomes necessary to give the following particulars of an interesting case of Palsy occasioned by a fall, attended with uncommon symptoms, related by Dr. Maty, in the third volume of the Medical Observations and Inquiries. The subject of this case, the Count de Lordat, had the misfortune to be overturned from a pretty high and steep bank. His head pitched against the top of the coach, and was bent from left to right; his left shoulder, arm, and especially his hand, were considerably bruised. At first he felt a good deal of pain along the left side of his neck, but neither then, nor at any other time, had he any faintings, vomitings, or giddiness.--On the sixth day he was let blood, on account of the pain in his shoulder and the contusion of his hand, which were then the only symptoms he complained of, and of which he soon found himself relieved.--Towards the beginning of the following winter, he began to find a small impediment in uttering some words, and his left arm appeared weaker. In the following spring, having suffered considerably from the severities of the winter campaign, he found the difficulty in speaking, and in moving his left arm, considerably increased.--On employing the thermal waters of Bourbonne, his speech become freer, but, on his return to Paris, the Palsy was increased, and the arm somewhat wasted.--In the beginning of the next spring he went to Balaruc; when he became affected with involuntary convulsive motions all over the body. The left arm withered more and more, a spitting began, and now it was with difficulty that he uttered a few words. Frictions and sinapisms were successively tried, and an issue, made by a caustic, was kept open for some time without any effect; but no mention is made of what part the issue was established in.

Soon after this, and three years and a half after the fall, Doctor Maty first saw the patient, and gives the following description of his situation. "A more melancholy object I never beheld. The patient, naturally a handsome, middle-sized, sanguine man, of a cheerful disposition, and an active mind, appeared much emaciated, stooping, and dejected. He still walked alone with a cane, from one room to the other, but with great difficulty, and in a tottering manner; his left hand and arm were much reduced, and would hardly perform any motion; the right was somewhat benumbed, and he could scarcely lift it up to his head; his saliva was continually trickling out of his mouth, and he had neither the power of retaining it, nor of spitting it out freely. What words he still could utter were monosyllables, and these came out, after much struggle, in a violent expiration, and with such a low voice and indistinct articulation, as hardly to be understood but by those who were constantly with him. He fetched his breath rather hard; his pulse was low, but neither accelerated nor intermitting. He took very little nourishment, could chew and swallow no solids, and even found great pain in getting down liquids. Milk was almost his only food; his body was rather loose, his urine natural, his sleep good, his senses, and the powers of his mind, unimpaired; he was attentive to, and sensible of every thing which was said in conversation, and shewed himself very desirous of joining in it; but was continually checked by the impediment in his speech, and the difficulty which his hearers were put to. Happily for him he was able to read, and as capable as ever of writing, as he shewed me, by putting into my hands an account of his present situation, drawn up by himself: and I am informed that he spent his time to the very last, in writing upon some of the most abstruse subjects."

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

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

Dr. Bellett offers the following explanation of these changes. "I conceive, that, by this accident, the head being violently bent to the right, the nervous membranes on the left were excessively stretched and irritated; that this cause extended by degrees to the spinal marrow, which being thereby compressed, brought on the paralytic symptoms, not only of the left arm, but at last in some measure also of the right. This induration seems to have been occasioned by the constant afflux of the nutritive juices, which were stopt at that place, and deprived of their most liquid parts; the grosser ones being unable to spread in the boney cavity, by which they were confined, could only acquire a greater solidity, and change a soft body into a hard and nearly osseous mass. This likewise accounts for the increase of the medulla oblongata, which being loaded with more juices than it could send off, swelled in the same manner as the branches of trees, which will grow of a monstrous size, when the sap that runs into them is stopt in its progress. The medulla oblongata not growing so hard as the spinalis, was doubtless owing to its not being confined in an osseous theca, but surrounded with soft parts, which allowed it room to spread. The obstruction from the bulk of this substance must have affected the brain, and probably induced the thickening of the pia mater, the hydatids, and the beginning of suppuration, whereas the dura mater, being of a harder texture, was not injured."

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.