 Preface to an essay of the Shaking Palsy. This is a LibriVox recording. All LibriVox recordings are in the public domain. For more information or to volunteer, please visit LibriVox.org. An essay of the Shaking Palsy by James Parkinson. Preface. The advantages which have been derived from the caution with which hypothetical statements are admitted are no instance more obvious than in those sciences which more particularly belong to the healing art. Therefore it 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, in that analogy is the substitute for anatomical examination, the only shore foundation for pathological knowledge. When however the nature of the subject and the circumstances under which it has here been taken up are considered, it is hoped that the offering of the following pages to the attention of the medical public will not be severely censored. 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 diseases of long duration to connect therefore the symptoms which occur in its later stages with those which mark its commencement requires a continuance of observation of the same case, or at least a correct history of its symptoms even for several years. Of both these advantages, the writer has had the opportunities of availing himself, and has hence been led particularly to observe several other cases in which the disease existed in different stages of its progress. By these repeated observations he hoped that he had been led to a probable conjecture as to the nature of the malady, and that analogy had suggested such means as might be productive of relief, and perhaps even of cure, if employed before the disease had been too long established. He therefore considered it to be a duty to submit his opinions to the examination of others, even in their present state of immaturity and imperfection. To delay their publication did not indeed appear to be warrantable. The disease had escaped particular notice, and the task of ascertaining its nature and caused by anatomical investigation did not seem likely to be taken up by those who from their abilities and opportunities were most likely to accomplish it. That these friends to humanity and medical science 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 precipitated 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. End of preface. Chapter 1 of an Essay of the Shaking Palsy by James Parkinson. This LibriVox recording is in the public domain. Chapter 1. Definition, History, Illustrative Cases. Shaking Palsy. Paralysis, Adjutants. In voluntary, tremulous motion, with lessen muscular power, imparts not in action and even when supported, with a propensity to bend the trunk forward and to pass from a walking to a running pace, the senses and intellects being un-enjoyed. The term shaking palsy has been vaguely employed by medical writers in general. By some it has been used to designate ordinary cases of palsy, of which some slight trumblings 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 a gallon, who marked its peculiar character by an appropriate term. The same symptom, it will also be seen, was accurately treated of by Silvius de la Boye. Junker also seems to have referred to this symptom, having divided tremor into active and passive. He says of the latter, ad affectus semi-paralyticos pertin de equalibus hygagimus chiqui tremores paralytroide vocantor. Tremor has been adopted as a genus by almost every nozologist, but always unmarked in their several definitions by such characters as would embrace this disease. The celebrated Cullen, with his accustomed accuracy, observes, tremorum utpote semper symptomaticum innumerum generum e sepere nohum. Species otum asa ve gisio e sensitas fraut mijae vel estena vel paralysios vel convulsiones symptomata esse virentor e subjuncum. 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 furnace the epithet by which the 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 12 months or more, the morbid influences felt in some other part. Thus assuming one of the hands and arms to be first attacked, the other at this period becomes similarly affected. For a few more months the patient is found to be less strict than usual in preserving upright posture, this being most observable whilst walking, but sometimes while sitting or standing. Sometimes after the appearance of this symptom, and during its slow increase, one of the legs is discovered slightly to tremble, and also found to suffer fatigue sooner than the leg of the other side. And in a few months this limb becomes agitated by similar trumblings, and suffers a similar loss of power. Hitherto the patient will have experienced but little inconvenience, and befriended by the strong influence of habitual endurance would perhaps seldom think of his being the subject of disease, except when reminded of it by the unsteadiness of his hand whilst writing or employing himself in any nicer kind of manipulation. But as the disease proceeds similar employments are accomplished with considerable difficulty, the hand failing to answer with exactness to the dictates of the will. Walking becomes a task which cannot be performed without considerable attention. The legs are not raised to that height or with that promptitude which the will directs, so that the utmost care is necessary to prevent frequent falls. At this period the patient experiences much inconvenience, which unhappily is found daily to increase. The submission of the limbs to the directions of the will can hardly ever be obtained in the performance of the most ordinary offices of life. The fingers cannot be disposed of in the proper directions and applied with certainty to any proposed point. As time and the disease proceed, difficulties increase. Writing can now be hardly at all accomplished, and reading from the tremulous motion is accomplished with some difficulty. Whilst at meals the fork not being duly directed frequently fails to raise the morsel from the plate, which when seized is with much difficulty conveyed to the mouth. At this period the patient seldom experiences a suspension of the agitation of his limbs, commencing for instance in one arm. The wearisome agitation is borne until beyond sufferance when by suddenly changing the posture it is for a time stopped in that limb to commence generally in less than a minute in one of the legs or in the arm of the other side. Arrest 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 the 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 fore part of the feet being at the same time irresistibly impelled to take much quicker and shorter steps and thereby to adopt unwillingly a running pace. In some cases it is found necessary entirely to substitute running for walking, since otherwise the patient on proceeding only a very few paces would inevitably fall. In this stage the sleep becomes much disturbed. The tremulous motion of the limbs occur during sleep and augment until they awaken the patient and frequently with much agitation and alarm. The power of conveying the food to the mouth is at length so much impeded that he is obliged to consent to be fed by others. The boughs which had been all along torbid now in most cases demand stimulating medicines of very considerable power. The expulsion of the feces from the rectum sometimes requiring mechanical aid. As the disease proceeds towards its last stage the trunk is almost permanently bowed. The muscular power is more decidedly diminished and the tremulous agitation becomes violent. The patient walks now with great difficulty and unable any longer to support himself with his stick. He dares not venture on this exercise. Unless assisted by an attendant who walking backwards before him prevents his falling forwards by the pressure of its hands against the forepart 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, etc. 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 at being directed to the back part of the fousis and hence is continually draining from the mouth mixed with the particles of food which he is no longer able to clear from the inside of the mouth. As the debility increases and the influence of the will over the muscles fades away the tremulous agitation becomes more vehement. It now seldom leaves him for a moment but even when exhausted nature ceases 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 immovably 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 feces are passed involuntarily and at the last constant sleeplessness with slight delirium and other marks of extreme exhaustion announced the wished for release. Case 1. Almost every circumstance noted in the preceding description was observed in a case which occurred several years back in which from the particular symptoms which manifested themselves in its progress. From the little knowledge of its nature acknowledged to be possessed by the physician who attended and from the mode of its termination excited an eager wish to acquire some further knowledge of its nature and cause. The subject of this case was a man rather more than fifty years of age who had industriously followed the business of a gardener leading a life of remarkable temperance and sobriety. The commencement of the malady was first manifested by a slight trembling of the left hand and arm, a circumstance which he 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 did not suffer 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 hemoplegia. In this case every circumstance occurred which has been mentioned in the preceding history. Case two. 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 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 four part of his feet and would have fallen every step if he had not been supported by a 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 spiritous 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 three. The next case was also noticed casually in the street. The subject of it was a man of about sixty-five years of age, of a remarkable athletic frame. The agitation of the limbs and indeed of the head and of the whole body was too vehement to allow it to be designated as trembling. He was entirely unable to walk, the body being so bowed and the head thrown so forward as to oblige him to go on a continued run and to employ his stick every five or six steps to force him more into an upright posture by projecting the point of it with great force against the pavement. He stated that he had been a sailor and attributed his complaints to having been for several months confined in a Spanish prison, where he had during the whole period of his confinement, lain upon the bare damp earth. The disease had here continued so long and made such a progress as to afford little or no prospect of relief. He besides was a poor mendicant requiring as well as the means of medical experiment those collateral aids which he could only obtain in a hospital. He was therefore recommended to make trial if any relief could in that mode be yielded him. The poor man, however, appeared to be by no means disposed to make the experiment. Case four. The next case which presented itself was that of a gentleman, about fifty-five years, who at 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 five. 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 to an extraordinary degree. It seemed to be necessary that the gentleman should be supported by his attendant, standing before him with a hand placed on each shoulder, until by gently swaying backward and forward, he had placed himself in equipoise. When giving the word he would start in a running pace, the attendant sliding from before him and running forward, being ready to receive him and prevent his falling after his having run about twenty paces. Case six. 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 occasion or disposed to this complaint, which he seems rather to regard as incidental upon his advanced age than as an object of medical attention. He, however, recollects that about twenty years ago he was troubled with lumbago which was severe and lasted some time. About eleven or twelve or perhaps more years ago he first perceived weakness in the left hand and arm, and soon after found the trembling commence. In about three years afterwards the right arm became affected in a similar manner, and soon afterwards the convulsive motions affected the whole body and began to interrupt the speech. In about three years from that time the legs became affected. Of late years the action of the bowels had been very much retarded and at two or three different periods had been made to yield to the action of very strong cathartics. But within the last twelve months this difficulty has not been so great, perhaps owing to an increased secretion of mucus which envelops the passing feces 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 hand that his face was much drawn to the left side. His medical attendant saw him the following day when he found him languid, with a small and quick pulse, but without pain in the head or disposition to sleep. Nothing more therefore was done then 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 palsy 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 paralyzed state was removed the shaking returned. At present he is almost constantly troubled with the agitation which he describes as generally commencing in a slight degree and gradually increasing until it arises to such a height as to shake the room. When by a sudden and somewhat violent change of posture he is almost always able to stop it, but very soon afterwards it will commence in some other limb in a small degree and gradually increase in violence. But he does not remember the thus checking of it to have been followed by any injurious effect. When the agitation had not been thus interrupted he stated that it gradually extended through all the limbs and at last affected the whole trunk. To illustrate his observation as to the power of suspending the motion by a sudden change of posture he, being then just come in from a walk with every limb shaking, threw himself rather violently into a chair and said, Now I am as well as ever I was in my life. The shaking completely stopped, but returned within two minutes time. He now possessed but little power in giving a required direction to the motions of any part. He was scarcely able to feed himself. He had written hardly intelligibly for the last three years and at present could not write at all. His attendants observed that of late the trembling would sometimes begin in his sleep and increase until it awakened him when he always was in a state of agitation and alarm. On being asked if he walked under much apprehension of falling forwards he said he suffered much from it and replied in the affirmative to the question whether he experienced any difficulty in restraining himself from getting into a running pace. It being asked if whilst walking he felt much apprehension from the difficulty of raising his feet. If he saw a rising pebble in his path he avowed in a strong manner his alarm on such occasions. And it was observed by his wife that she believed that in walking across the room he would consider as a difficulty than 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. End of Chapter 1 Chapter 2 of an Essay of the Shaking Palsy by James Parkinson Chapter 2 Pathognomonic Symptoms Examined Tremor Coactus Skeletir B. Festinens 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 riders respecting them seem necessary to be attempted. First, involuntary tremulous motion with less involuntary 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 as for the sake of giving to it its proper designation, as for assisting in forming probable conjectures as to the nature of the malady which it helps to characterize. Tremors were distinguished by Joker into active, those preceding from sudden affection of the minds, as terror, anger, etc., and passive, dependent on debilitating causes, such as advanced age, palsy, etc. But a much more satisfactory and useful distinction is made by Silvia's De La Boe, into those tremors which are produced by attempts at voluntary motion and those which occur whilst the body is at rest. Sauvages distinguishes the latter of these species, tremor, coactus, by observing that the tremulous parts leap, and as it were vibrant even when supported, whilst every other tremor he observes ceases when the voluntary exertion removing the limb stops, or the part is supported, but returns when we will the limb to move. Once he says tremor is distinguished from every other kind of spasm, 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 Sweden. In Stichuerre Trimet, palpitantes atum partes etium incuiete fuerent, etiem si nullum illus motum in Duxerres, palpitant, ideoprimum posteriorum, modum descriptum tremores spesium, quando coesente omene, omene involtarius, illus et alternus motumum, moribus agitantor membra, palpitatiorum. Cronum digit posteriorum primum verum, quando un fit misi omen, omo conetur partes, quasdam muvere tremoram vocavi. Under this authority the term palpitation may be employed to mark those morbid motions which chiefly characterize this disease, notwithstanding that this term has been anticipated by Sauvages as characteristic of another species of tremor. The separation of palpitations with the limbs, polymos of Galen, tremores coactus of Delaboi, 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 in 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 a malady here treated up, whilst his hand and arm is palpitating strongly, will seize his pencil, and the motions will be suspended. Allow 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. 2. A propensity to bend the trunk forwards and to pass from a walking to a running pace. This affection, which observation seems to authorize the being considered as a symptom peculiar to this disease, has been mentioned by few nosologists. It appears to have been first noticed by Gavius, 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 fall to the muscles belonging to speech, nor yet of these alone, I have seen one who was able to run but not to walk. Selvages referring to this symptom says another disease, which has been very rarely seen by authors, appears to be referable to the same genus. Skeletarbe, of which he makes Corea Satevite, the first species, which he says I think cannot be more fitly named than hastening or hurrying. Skeletarbe, he says, is a peculiar species of Skeletarbe, in which the patients, whilst wishing to walk in the ordinary mode, are forced to run, which has been seen by Cargay and by the illustrious Galbius. A similar affection of the speech, when the tongue thus outruns the mind, is termed viability. Mansur de Savage attributes this complaint to a want of flexibility in the muscular fibers, hence he supposes that the patients make shorter steps and strive a more than common exertion or impetus to overcome the resistance, walking with a quick and hastened step as if hurrying along against their will. Corea Vite, he says, attacks the youth of both sexes, but this disease only thus advances in years, in 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. Having made the necessary inquiries respecting these two affections, Tremor coactum of Silvius de La Boe and of Savages and Skeletarbe Castinens of the latter nozologist, which appears to be characteristic symptoms of this disease, it becomes necessary in the next place to endeavor to distinguish this disease from others which may bear resemblance of it in some particular respects. End of Chapter 2 Chapter 3 of an Essay of the Shaking Palsy by James Parkinson. This LibriVox recording is in the public domain. Chapter 3. Shaking Palsy distinguished from other diseases with which it may be confounded. Trading 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 endeavoring the market's diagnostic characters. It is sufficient in general to point out the characteristic differences which are observable between the diseases in some respects resembling each other. But in this case, more is required. It is necessary to show that it is a disease which does not accord with any which are marked in the systematic arrangements of nozologists, 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 palsy limbs become affected with tremulous motions be confounded with this disease. In those cases, the abolition or diminution of a voluntary muscle 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 affection 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 here been denominated shaking palsy. Dr. Kirkland in his commentary on epileptic and paralytic affections, etc., 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 in a 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 with 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. The 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 were 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 proved a verma-fuge. 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 prescribed 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 characterized 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 cullin, or to hierenosos of lineus and vogel. The latter appears to be referable to that class of proteal forms of disease generated by disordered state of primae vi, sympathetically affecting the nervous influence in the distant part of the body. The less attention is paid to one's circumstance, this disease will be confounded with those species of passive trumblings to which the term shaking palsy has frequently been applied. These are tremor temulentus, the trembling consequent to indulgence in the drinking of spiritus liquors, that which proceeds from the immoderate employment of tea and coffee, that which appears to be dependent on advanced age, and all those trumblings 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 already been 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. End of Chapter 3 Chapter 4 of an Essay of the Shaking Palsy by James Parkinson. This LibriVox recording is in the public domain. Chapter 4 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 quite unfavorable circumstances, provided 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 disease 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. Uncertainly existing as to the nature of the proximate cause of this disease, its remote causes must necessarily be referred to in decision. 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 enclosed. 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 precede inflammation of quicker or 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, etc. But in no case which has been noticed as 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 lie 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 26 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 palpatory 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 chair's 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 twelve months. 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 carrier 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. While 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. Tend it with uncommon symptoms related by Dr. Matty in the third volume of the medical observations and inquiries. The subject of this case the Count de Lorda 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 had any faintings, vomiting or giddiness. On the sixth day he was let blood on account of the pain in his shoulder and the contusion on 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. Upon employing the thermal waters of Bourbon his speech became 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 Bellarue where 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 synapses 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 Dr. Mady 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, pure 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 benumb 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 it is 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 intermittent. 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 and he was attentive to and sensible of everything which was said in conversation and showed himself very desirous of joining in 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 showed 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 obstruous subjects. This gentleman died about four years after the accident when the body was examined by Dr. Bellet and Montsourbier 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 tenderness. The dora mater was in a sound state but the piha mater was full of blood and lymph. On it several hyda dids and towards the phallic some marks of serpiration were observed. The ventricles were filled with water and the plexus coroitis was considerably enlarged and stuffed with grumas 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 that was greatly enlarged, surpassing the usual side by more than one third. It was likewise more compact. The membranes which in their continuation enclosed 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 tenderness 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 labor to cut them asunder as the ribs. Like those they were spongy 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 ilium 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. Bellet observes the following explanation of these changes. I conceived 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 enduration seemed to have been occasioned by the constant afflux of the nutritive juices which were stopped at that place and deprived of most liquid parts. The grosser ones being unable to spread in the bony cavity by which they were confined could only acquire a greater solidity and change a soft body into a hard and nearly oseous mass. This likewise accounts for the increase of the medulla oblongata which was 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 stopped in its progress. The medulla oblongata not growing so hard as the spinalis was doubtless owing to its not being confined in an oseous thaca 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 peahum mater behind the tids and the beginning of separation whereas the dorum mater being of a harder texture was not injured. The symptoms which appeared in this case and 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 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 the assumed occasional causes whilst congesting as to the cause of this disease the following collected observations on the effects of injury to the spinalis by sir ever at home become particularly deserving of attention it then 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 35 days but the urine and stools passed involuntarily blood extravastated in the central part of the medulla in the neck was attended with paralytic affection of the legs but not of the arms 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 esophagus was so sensible that solids could not account of the pain the occasion when the medulla of the back was completely divided there was momentary loss of sight loss of memory for 15 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 in two of the cases already noticed symptoms of rheumatism had previously existed in case 4 the right arm in which the palpitation began was said to have been very violently affected with rheumatic pain to the finger 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 a position 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 that 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 forearm and on the sides of the fingers 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 forearm back part of the chest was slightly augmented by growing a deep breath these circumstances suggested the probability of slight information or increased determination to the origin of the nerves of those parts again to the neighboring 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 anti-mone heels and the following morning the bowels were evacuated by an appropriate dose of Kalamel on the following day the pains were much finished 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 exercise the strength of the arm was not completely recovered at the end of more than 12 months and after more than twice that time exertion would excite the feeling of painful weariness but no palpitation or other unpleasant symptom has occurred during the five or six years which have since passed the commencement progress and termination of this attack with the success attending the mode of treatment and the symptoms which followed seem to lead to the conjecture that the proximate cause of the disease in this case existed in the medulla spinalis and that it might have 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 40 years of age complaining of great pain in both the arms extending from the shoulder to the fingertips 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 four weeks it gradually amended leaving both the arms and hands in a very weakened and trembling state from this state they were now somewhat recovered but she was extremely anxious during 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 in a blister which was made for some time to yield a purulent discharge were applied over the cervical vertebrae and in the course of a very few days the pain was entirely removed it is regretted that no farther information as to the progress of this case could be obtained on meeting with these two cases it was thought that it might not be improbable that attacks of this kind considered at the time merely as rheumatic affections might lay the foundation of this lamentable disease which might manifest itself at some distant period when the circumstance in which it had originated had perhaps almost escaped the memory indeed when it is considered that neither in the extraordinary case of palsy of the lower extremities proceeding from diseased spine nor cases of injured medulla from fractured vertebrae any of the peculiar symptoms of this disease are observable we necessarily doubt as to the probability of its being the direct effect of any sudden injury but taking all circumstances in due consideration particularly the very gradual matter in which the disease commences and proceeds in its attacks as well as the inability to ascribe its origin to any more obvious cause were 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 scrophilis affection it must be too obvious that the evidence adduced as to the nature of the proximate and occasional causes of this disease is by no means conclusive a reference to the test therefore which will be yielded by an examination of some of the more prominent symptoms especially as to their agreement with the supposed proximate cause is more particularly demanded satisfied as to the important 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 etc 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 just been offered respecting the cause or at least the seat for 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 had in trunk have then become gradually affected and lastly the muscles of the mouth and fosses have yielded to the morbid influence the arms parts first manifesting disordered action of course direct us whilst searching for the cause of these changes to the brachial nerves by finding the mischief extending to other parts not supplied with these but with other nerves derived from merely the same part of the medulla spinalis we're 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 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 the nervous power at pace is also referable to such a diminution of the nervous power in the extensor muscles of the head and neck as prevents them from performing the offices of maintaining that in body and in 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 changes 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 last occurrence of this set of symptoms the extension upwards of the diseased state a very close agreement is observable between this disease and that which has been already shown prove fatal to the count de la 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 end of chapter four chapter five of an essay of the shaking policy by James Parkinson this LibriVox recording is in the public domain chapter five considerations respecting the means of cure the inquiries made in the proceeding pages yield it is to be much regretted but little more than evidence of inference nothing direct and satisfactory has been obtained all that has been ventured to assume here has been that the disease depends on a disordered state of that part of the medulla which is contained in the cervical vertebrae but of what nature that morbid changes and whether alternating in the medulla itself in its membrane or in the containing pica 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 air long be discovered by which at least the progress of the disease may be stopped it seldom happens that the agitation extends beyond the arms within the first two years which period therefore if we were disposed to divide the disease into stages might be said to comprise the first stage in this period it is very probable that remedial means might be employed with success and even if unfortunately deterred to a later period you might then arrest the farther 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 laudat 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 vehicle ligament the membranes or the medulla itself may pass into the state of simple excitement or irritation which may be gradually seceded by such a local afflux and determination of blood into the minute vessels as may terminate an actual but slow inflammation the result of this would be a thickening of the feca or membranes 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 laudat the chance of relief from the proposed mode of treatment may appear to be sufficient to warrant its trial in such case then at whatever period of the disease it might be proposed to attempt the cure blood should first be taken from the upper part of the neck unless contraindicated by any particular circumstance after which vesicatory should be applied to the same part and a purulent discharge obtained by appropriate use of the sabon liniment having recourse to the application of a fresh blister when from the diminution of the discharging surface puss 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 column in its superior part these it is presumed would be best formed with kept open with any proper substance could it have been imagined that such considerable benefit indeed that such astonishing cures could have been affected by issues in case of palsy of the lower extremities from diseased spine although satisfied with describing these cases to scruffulous action we are in fact as little inform respect in the nature of the affection inducing the carrier state of the vertebrae as we are respecting the peculiar changes 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 perulent neighborhood 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 remedies are resorted to the greater will be the probability of success but in this disease there is one circumstance which demands particular attention long period to which it may be extended one of the peculiar symptoms skelly otter be festinous may not occur until the disease has existed 10 or 12 years or more hence we're looking for the period within which our hopes of remedial aid is to be limited we may guide it by the slow progress of the malady extended 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 and 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 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 they seen the train of harassing evils which would thus avoid it but it seems as if there exist a 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 perulent discharge in a neighboring part act in the discharge we would presume that 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 absorbance 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 respect in the nature of this disease the employment of internal medicines is scarcely warrantable unless analogy should point out some remedy the trial of which rational hope might authorize particular circumstances indeed must arise in different cases 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 muscle and the affected parts is so prominent a symptom as to be very liable to mislead the inattentive who may regard the disease as a near consequence of constitutional ability if this notion be pursued in 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 50 and frequently yielding but little inconvenience for several months it is generally considered as the irremediable diminution of the nervous influence naturally resulting from declining life and remedies therefore are seldom sought for although unable to trace the connection by which a disordered state of the stomach and bowels may induce a morbid action in the part of the medulla spinalis yet taught by the instruction of Mr. Abernethy little hesitation need be employed before to determine on the probability of such currents 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 stimulates 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 a b a man 54 years of age of temperate habits in 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 fullness 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 appear to be no marks of vascular fullness it was determined to empty the bowels this was done effectually by moderate doses of calomel with the occasional help of epsom salt and in about ten days by these means alone the complaints were entirely removed before concluding these pages it may be proper to observe once more that an important object proposed to be obtained by them is the leading of the attention of those who humanely employ anatomical examination in detecting the causes in nature of diseases particularly to this malady by their benevolent labors its real nature may be ascertained in appropriate modes of relief or even of cure pointed out to such research as 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 art 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 yield by the philanthropic exertions of a howard but how few can estimate the benefits bestowed on mankind by the labors of a morgani hunter or bailey end of chapter 5 end of an essay of the shaking palsy by james parkinson