Read Ebook: An Essay on the Shaking Palsy by Parkinson James

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"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.

"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.

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

These circumstances suggested the probability of slight inflammation, or increased determination to the origin of the nerves of these parts, and to the neighbouring medulla. On this ground, blood was taken from the back part of the neck, by cupping; hot fomentations were applied for about the space of an hour, when the upper part of the back of the neck was covered with a blister, perspiration was freely induced by two or three small doses of antimonials, and the following morning the bowels were evacuated by an appropriate dose of calomel. On the following day the pains were much diminished, and in the course of four or five days were quite removed. The arm and hand felt now more than ordinarily heavy, and were evidently much weakened: aching, and feeling extremely wearied after the least exertion. The strength of the arm was not completely recovered at the end of more than twelvemonths; and, after more than twice that time, exertion would excite the feeling of painful weariness, but no palpitation or other unpleasant symptom has occurred during the five or six years which have since passed.

The commencement, progress, and termination of this attack; with the success attending the mode of treatment, and the symptoms which followed, seem to lead to the conjecture, that the proximate cause of the disease, in this case, existed in the medulla spinalis, and that it might, if neglected, have gradually resolved itself into that disease which is the object of our present inquiry.

Some few months after the occurrence of the preceding case, the writer of these lines was called to a female about forty years of age, complaining of great pain in both the arms, extending from the shoulder to the finger ends. She stated, that she was attacked in the same manner as is described in the preceding case, about nine months before; that the complaint was considered as rheumatism, and was not benefited by any of the medicines which had been employed; but that after three or four weeks it gradually amended, leaving both the arms and hands in a very weakened and trembling state. From this state they were now somewhat recovered; but she was extremely anxious, fearing that if the present attack should not be soon checked, she might entirely lose the use of her hands and arms.

Instructed by the preceding case, similar means were here recommended. Leeches, stimulating fomentations, and a blister, which was made for sometime to yield a purulent discharge, were applied over the cervical 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 ordinary cases of Palsy of the lower extremities, proceeding from diseased spine, nor in 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 into due consideration, particularly the very gradual manner in which the disease commences, and proceeds in its attacks; as well as the inability to ascribe its origin to any more obvious cause, we are led to seek for it in some slow morbid change in the structure of the medulla, or its investing membranes, or theca, occasioned by simple inflammation, or rheumatic or scrophulous affection.

It must be too obvious that the evidence adduced as to the nature of the proximate and occasional causes of this disease, is by no means conclusive. A reference to the test therefore which will be yielded by an examination of some of the more prominent symptoms, especially as to their agreement with the supposed proximate cause, is more particularly demanded. Satisfied as to the importance of this part of the present undertaking, no apology is offered for the extent to which the examination is carried on.

If the palpitation and the attendant weakness of the limbs, &c. be considered as to the order in which the several parts are attacked, it is believed, that some confirmation will be obtained of the opinion which has been just offered, respecting the cause, or at least the seat, of that change which may be considered as the proximate cause of this disease.

One of the arms, in all the cases which have been here mentioned, has been the part in which these symptoms have been first noticed; the legs, head, and trunk have then become gradually affected, and lastly, the muscles of the mouth and fauces have yielded to the morbid influence.

The arms, the parts first manifesting disordered action, of course direct us, whilst searching for the cause of these changes, to the brachial nerves. But finding the mischief extending to other parts, not supplied with these, but with other nerves derived from nearly the same part of the medulla spinalis, we are of course led to consider that portion of the medulla spinalis itself, from which these nerves are derived, as the part in which those changes have taken place, which constitute the proximate cause of this disease.

From the subsequent affection of the lower extremities, and from the failure of power in the muscles of the trunk, such a change in the substance of the medulla spinalis may be inferred, as shall have considerably interrupted, and interfered with, the extension of the nervous influence to those parts, whose nerves are derived from any portion of the medulla below the part which has undergone the diseased change.

The difficulty in supporting the trunk erect, as well as the propensity to the adopting of a hurried pace, is also referable to such a diminution of the nervous power in the extensor muscles of the head and trunk, as prevents them from performing the offices of maintaining the head and body in an erect position.

From the impediment to speech, the difficulty in mastication and swallowing, the inability to retain, or freely to eject, the Saliva, may with propriety be inferred an extension of the morbid change upwards through the medulla spinalis to the medulla oblongata, necessarily impairing the powers of the several nerves derived from that portion into which the morbid change may have reached. In the late occurrence of this set of symptoms, and the extension upwards of the diseased state, a very close agreement is observable between this disease and that which has been already shown, proved fatal to the Count de Lordat. But in this case, the disease doubtlessly became differently modified, and its symptoms considerably accelerated, in consequence of the magnitude of the injury by which the disease was induced.

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 vertebrae. But of what nature that morbid change is; and whether originating in the medulla itself, in its membranes, or in the containing theca, is, at present, the subject of doubt and conjecture. But although, at present, uninformed as to the precise nature of the disease, still it ought not to be considered as one against which there exists no countervailing remedy.

On the contrary, there appears to be sufficient reason for hoping that some remedial process may ere long be discovered, by which, at least, the progress of the disease may be stopped. It seldom happens that the agitation extends beyond the arms within the first two years; which period, therefore, if we were disposed to divide the disease into stages, might be said to comprise the first stage. In this period, it is very probable, that remedial means might be employed with success: and even, if unfortunately deferred to a later period, they might then arrest the farther progress of the disease, although the removing of the effects already produced, might be hardly to be expected.

From a review of the changes which had taken place in the case of Count de Lordat, it seems as if we were able to trace the order and mode in which the morbid changes may proceed in this disease. From any occasional cause, the thecal ligament, the membranes, or the medulla itself, may pass into the state of simple excitement or irritation, which may be gradually succeeded by such a local afflux and determination of blood into the minute vessels, as may terminate in actual but slow inflammation. The result of this would be a thickening of the theca, or membranes, and perhaps an increase in the volume of the medulla itself, which would gradually occasion such a degree of pressure against the sides of the unyielding canal, as must eventually intercept the influence of the brain upon the inferior portion of the medullary column, and upon the parts on which the nerves of this portion are disposed.

From this review, and assuming that the morbid changes in this disease may not be widely dissimilar from those which occurred in the case of Count de Lordat, the chance of relief from the proposed mode of treatment may appear to be sufficient to warrant its trial.

In such a case then, at whatever period of the disease it might be proposed to attempt the cure, blood should be first taken from the upper part of the neck, unless contra-idicated by any particul circumstance. After which vesicatories should be applied to the me part, and a purulent discharge obtained by appropriate use of the Sabine Liniment; having recourse to the application of a fresh blister, when from the diminution of the discharging surface, pus is not secreted in a sufficient quantity. Should the blisters be found too inconvenient, or a sufficient quantity of discharge not be obtained thereby, an issue of at least an inch and a half in length might be established on each side of the vertebral columna, in its superior part. These, it is presumed, would be best formed with caustic, and kept open with any proper substance.

Could it have been imagined that such considerable benefit: indeed, that such astonishing cures, could have been effected by issues in cases of Palsy of the lower extremities from diseased spine? although satisfied with ascribing those cases to scrofulous action, we are in fact as little informed respecting the nature of the affection, inducing the carious state of the vertebrae, as we are respecting the peculiar change of structure which takes place in this disease. Equally uninformed are we also as to the peculiar kind of morbid action, which takes place in the ligaments of the joints; as well as that which takes place in different instances of deep seated pains and affections of the parts contained in the head, thorax, and abdomen, and in all which cases the inducing of a purulent discharge in their neighbourhood is so frequently productive of a cure. Experiment has not indeed been yet employed to prove, but analogy certainly warrants the hope, that similar advantages might be derived from the use of the means enumerated, in the present disease. It is obvious, that the chance of obtaining relief will depend in a great measure on the period at which the means are employed. As in every other disease, so here, the earlier the remedies are resorted to, the greater will be the probability of success. But in this disease there is one circumstance which demands particular attention; the long period to which it may be extended. One of its peculiar symptoms, Scelotyrbe festinans, may not occur until the disease has existed ten or twelve years, or more; hence, when looking for the period, within which our hopes of remedial aid is to be limited; we may, guided by the slow progress of the malady, extend it to a great length, when compared with that within which we should be obliged to confine ourselves in most other diseases.

But it is much to be apprehended, as in many other cases, that the resolution of the patients will seldom be sufficient to enable them to persevere through the length of time which the proposed process will necessarily require. As slow as is the progress of the disease, so slow in all probability must be the period of the return to health. In most cases, especially in those in which the disease has been allowed to exist long unopposed, it may be found that all that art is capable of accomplishing, is that of checking its further progress. Nor will this be regarded as a trifle, when, by reference to the history of the disease, is seen the train of harassing evils which would be thus avoided.

But it seems as if there existed reason for hoping for more. For supposing change of structure to have taken place, it is extremely probable that this change may be merely increase in mass or volume by interstitial addition, the consequence of increased action in the minute vessels of the part. In that case, should the instituting of a purulent discharge, in a neighbouring part, act in the manner which we would presume it may--should it by keeping up a constant discharge, not merely alter the determination, but diminish the inordinate action of the vessels in the diseased part; and at the same time excite the absorbents to such increased action as may remove the added matter; there will exist strong ground for hope, that a happy, though slow restoration to health, may be obtained.

Until we are better informed respecting the nature of this disease, the employment of internal medicines is scarcely warrantable; unless analogy should point out some remedy the trial of which rational hope might authorize. Particular circumstances indeed must arise in different cases, in which the aid of medicine may be demanded: and the intelligent will never fail to avail themselves of any opportunity of making trial of the influence of mercury, which has in so many instances, manifested its power in correcting derangement of structure.

The weakened powers of the muscles in the affected parts is so prominent a symptom, as to be very liable to mislead the inattentive, who may regard the disease as a mere consequence of constitutional debility. If this notion be pursued, and tonic medicines, and highly nutritious diet be directed, no benefit is likely to be thus obtained; since the disease depends not on general weakness, but merely on the interruption of the flow of the nervous influence to the affected parts.

It is indeed much to be regretted that this malady is generally regarded by the sufferers in this point of view, so discouraging to the employment of remedial means. Seldom occurring before the age of fifty, and frequently yielding but little inconvenience for several months, it is generally considered as the irremediable diminution of the nervous influence, naturally resulting from declining life; and remedies therefore are seldom sought for.

Although unable to trace the connection by which a disordered state of the stomach and bowels may induce a morbid action in a part of the medulla spinalis, yet taught by the instruction of Mr. Abernethy, little hesitation need be employed before we determine on the probability of such occurrence. The power, possessed by sympathy, of inducing such disordered action in a distant part, and the probability of such disordered action producing derangement of structure, can hardly be denied. The following Case seems to prove, at least, that the mysterious sympathetic influence which so closely simulates the forms of other diseases, may induce such symptoms as would seem to menace the formation of a disease not unlike to that which we have been here treating of.

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.

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.

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