An Essay on the Shaking Palsy

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, in which some slight tremblings have occurred; whilst by others it has been applied to certain anomalous affections, not belonging to Palsy.

The shaking of the limbs belonging to this disease was particularly noticed, as will be seen when treating of the symptoms, by Galen, who marked its peculiar character by an appropriate term. The same symptom, it will also be seen, was accurately treated of by Sylvius de la Boë. Juncker also seems to have referred to this symptom: having divided tremor into active and passive, he says of the latter, “ad affectus semiparalyticos pertinant; de qualibus hic agimus, quique tremores paralytoidei vocantur.” Tremor has been adopted, as a genus, by almost every nosologist; but always unmarked, in their several definitions, by such characters as would embrace this disease. The celebrated Cullen, with his accustomed accuracy observes, “Tremorem, utpote semper symptomaticum, in numerum generum recipere nolem; species autem a Sauvagesio recensitas, prout mihi vel astheniae vel paralysios, vel convulsionis symptomata esse videntur, his subjungam.”^* Tremor can indeed only be considered as a symptom, although several species of it must be admitted. In the present instance, the agitation produced by the peculiar species of tremor, which here occurs, is chosen to furnish the epithet by which this species of Palsy, may be distinguished.

So slight and nearly imperceptible are the first inroads of this malady, and so extremely slow its progress, that it rarely happens, that the patient can form any recollection of the precise period of its commencement. The first symptoms perceived are, a slight sense of weakness, with a proneness to trembling in some particular part; sometimes in the head, but most commonly in one of the hands and arms. These symptoms gradually increase in the part first affected; and at an uncertain period, but seldom in less than twelvemonths or more, the morbid influence is felt in some other part. Thus assuming one of the hands and arms to be first attacked, the other, at this period becomes similarly affected. After a few more months the patient is found to be less strict than usual in preserving an upright posture: this being most observable whilst walking, but sometimes whilst sitting or standing. Sometime after the appearance of this symptom, and during its slow increase, one of the legs is discovered slightly to tremble, and is also found to suffer fatigue sooner than the leg of the other side: and in a few months this limb becomes agitated by similar tremblings, and suffers a similar loss of power.

Hitherto the patient will have experienced but little inconvenience; and befriended by the strong influence of habitual endurance, would perhaps seldom think of his being the subject of disease, except when reminded of it by the unsteadiness of his hand, whilst writing or employing himself in any nicer kind of manipulation. But as the disease proceeds, similar employments are accomplished with considerable difficulty, the hand failing to answer with exactness to the dictates of the will. Walking becomes a task which cannot be performed without considerable attention. The legs are not raised to that height, or with that promptitude which the will directs, so that the utmost care is necessary to prevent frequent falls.

At this period the patient experiences much inconvenience, which unhappily is found daily to increase. The submission of the limbs to the directions of the will can hardly ever be obtained in the performance of the most ordinary offices of life. The fingers cannot be disposed of in the proposed directions, and applied with certainty to any proposed point. As time and the disease proceed, difficulties increase: writing can now be hardly at all accomplished; and reading, from the tremulous motion, is accomplished with some difficulty. Whilst at meals the fork not being duly directed frequently fails to raise the morsel from the plate: which, when seized, is with much difficulty conveyed to the mouth. At this period the patient seldom experiences a suspension of the agitation of his limbs. Commencing, for instance in one arm, the wearisome agitation is borne until beyond sufferance, when by suddenly changing the posture it is for a time stopped in that limb, to commence, generally, in less than a minute in one of the legs, or in the arm of the other side. Harassed by this tormenting round, the patient has recourse to walking, a mode of exercise to which the sufferers from this malady are in general partial; owing to their attention being thereby somewhat diverted from their unpleasant feelings, by the care and exertion required to ensure its safe performance.

But as the malady proceeds, even this temporary mitigation of suffering from the agitation of the limbs is denied. The propensity to lean forward becomes invincible, and the patient is thereby forced to step on the toes and fore part of the feet, whilst the upper part of the body is thrown so far forward as to render it difficult to avoid falling on the face. In some cases, when this state of the malady is attained, the patient can no longer exercise himself by walking in his usual manner, but is thrown on the toes and forepart of the feet; being, at the same time, irresistibly impelled to take much quicker and shorter steps, and thereby to adopt unwillingly a running pace. In some cases it is found necessary entirely to substitute running for walking; since otherwise the patient, on proceeding only a very few paces, would inevitably fall.

In this stage, the sleep becomes much disturbed. The tremulous motion of the limbs occur during sleep, and augment until they awaken the patient, and frequently with much agitation and alarm. The power of conveying the food to the mouth is at length so much impeded that he is obliged to consent to be fed by others. The bowels, which had been all along torpid, now, in most cases, demand stimulating medicines of very considerable power: the expulsion of the faeces 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 his hands against the fore part of his shoulders. His words are now scarcely intelligible; and he is not only no longer able to feed himself, but when the food is conveyed to the mouth, so much are the actions of the muscles of the tongue, pharynx, &c. impeded by impaired action and perpetual agitation, that the food is with difficulty retained in the month until masticated; and then as difficultly swallowed. Now also, from the same cause, another very unpleasant circumstance occurs: the saliva fails of being directed to the back part of the fauces, and hence is continually draining from the mouth, mixed with the particles of food, which he is no longer able to clear from the inside of the mouth.

As the debility increases and the influence of the will over the muscles fades away, the tremulous agitation becomes more vehement. It now seldom leaves him for a moment; but even when exhausted nature seizes a small portion of sleep, the motion becomes so violent as not only to shake the bed-hangings, but even the floor and sashes of the room. The chin is now almost immoveably bent down upon the sternum. The slops with which he is attempted to be fed, with the saliva, are continually trickling from the mouth. The power of articulation is lost. The urine and faeces are passed involuntarily; and at the last, constant sleepiness, with slight delirium, and other marks of extreme exhaustion, announce the wished-for release.

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

The subject of this case was a man rather more than fifty years of age, who had industriously followed the business of a gardener, leading a life of remarkable temperance and sobriety. The commencement of the malady was first manifested by a slight trembling of the left hand and arm, a circumstance which he was disposed to attribute to his having been engaged for several days in a kind of employment requiring considerable exertion of that limb. Although repeatedly questioned, he could recollect no other circumstance which he could consider as having been likely to have occasioned his malady. He had not suffered much from Rheumatism, or been subject to pains of the head, or had ever experienced any sudden seizure which could be referred to apoplexy or hemiplegia. In this case, every circumstance occurred which has been mentioned in the preceding history.

The subject of the case which was next noticed was casually met with in the street. It was a man sixty-two years of age; the greater part of whose life had been spent as an attendant at a magistrate's office. He had suffered from the disease about eight or ten years. All the extremities were considerably agitated, the speech was very much interrupted, and the body much bowed and shaken. He walked almost entirely on the fore part of his feet, and would have fallen every step if he had not been supported by his stick. He described the disease as having come on very gradually, and as being, according to his full assurance, the consequence of considerable irregularities in his mode of living, and particularly of indulgence in spirituous liquors. He was the inmate of a poor-house of a distant parish, and being fully assured of the incurable nature of his complaint, declined making any attempts for relief.

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 an hospital. He was therefore recommended to make trial if any relief could, in that mode, be yielded him. The poor man, however, appeared to be by no means disposed to make the experiment.

The next case which presented itself was that of a gentleman about fifty-five years, who had first experienced the trembling of the arms about five years before. His application was on account of a considerable degree of inflammation over the lower ribs on the left side, which terminated in the formation of matter beneath the fascia. About a pint was removed on making the necessary opening; and a considerable quantity discharged daily for two or three weeks. On his recovery from this, no change appeared to have taken place in his original complaint; and the opportunity of learning its future progress was lost by his removal to a distant part of the country.

In another case, the particulars of which could not be obtained, and the gentleman, the lamented subject of which was only seen at a distance, one of the characteristic symptoms of this malady, the inability for motion, except in a running pace, appeared to exist in an extraordinary degree. It seemed 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.

In a case which presented itself to observation since those above-mentioned, every information as to the progress of the malady was very readily obtained. The gentleman who was the subject of it is seventy-two years of age. He has led a life of temperance, and has never been exposed to any particular situation or circumstance which he can conceive likely to have occasioned, or disposed to this complaint; which he rather seems to regard as incidental upon his advanced age, than as an object of medical attention. He however recollects, that about twenty years ago, he was troubled with lumbago, which was severe and lasted some time. About eleven or twelve, or perhaps more, years ago, he first perceived weakness in the left hand and arm, and soon after found the trembling commence. In about three years afterwards the right arm became affected in a similar manner: and soon afterwards the convulsive motions affected the whole body, and began to interrupt the speech. In about three years from that time the legs became affected. Of late years the action of the bowels had been very much retarded; and at two or three different periods had, with great difficulty, been made to yield to the action of very strong cathartics. But within the last twelvemonths this difficulty has not been so great; perhaps owing to an increased secretion of mucus, which envelopes the passing faeces, and which precedes and follows their discharge in considerable quantity.

About a year since, on waking in the night, he found that he had nearly lost the use of the right side, and that the face was much drawn to the left side. His medical attendant saw him the following day, when he found him languid, with a small and quick pulse, and without pain in the head or disposition to sleep. Nothing more therefore was done than to promote the action of the bowels, and apply a blister to the back of the neck, and in about a fortnight the limbs had entirely recovered from their palsied state. During the time of their having remained in this state, neither the arm nor the leg of the paralytic side was in the least affected with the tremulous agitation; but as their paralysed state was removed, the shaking returned.

At present he is almost constantly troubled with the agitation, which he describes as generally commencing in a slight degree, and gradually increasing, until it arises to such a height as to shake the room; when, by a sudden and somewhat violent change of posture, he is almost always able to stop it. But very soon afterwards it will commence in some other limb, in a small degree, and gradually increase in violence; but he does not remember the thus checking of it, to have been followed by any injurious 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 difficulty the having to step over a pin.

It is necessary that the peculiar nature of this tremulous motion should be ascertained, as well for the sake of giving to it its proper designation, as for assisting in forming probable conjectures, as to the nature of the malady, which it helps to characterise. Tremors were distinguished by Juncker into Active, those proceeding from sudden affection of the minds, as terror, anger, &c. and Passive, dependant on debilitating causes, such as advanced age, palsy, &c.^* But a much more satisfactory and useful distinction is made by Sylvius de la Boë into those tremors which are produced by attempts at voluntary motion, and those which occur whilst the body is at rest.^† Sauvages distinguishes the latter of these species (Tremor Coactus) by observing, that the tremulous parts leap, and as it were vibrate, even when supported: whilst every other tremor, he observes, ceases, when the voluntary exertion for moving the limbs stops, or the part is supported, but returns when we will the limb to move; whence, he says, tremor is distinguished from every other kind of spasm.^‡

A small degree of attention will be sufficient to perceive, that Sauvages, by this just distinction, actually separates this kind of tremulous motion, and which is the kind peculiar to this disease, from the Genus Tremor. In doing this he is fully warranted by the observations of Galen on the same subject, as noticed by Van Swieten.^§ “Binas has tremoris species^‖ Galenus subtiliter distinxit, atque etiam diversis nominibus insignivit, tremor enim (τρομοσ) facultatis corpus moventis et vehentis infirmitate oboritur. Quippe nemo, qui artus movere non instituerit tremet. Palpitantes autem partes, etiam in quiete fuerint, etiamsi nullum illis motum induxeris palpitant. Ideo primam (posteriorem) modo descriptam tremoris speciem, quando quiescenti homini involuntariis illis et alternis motibus agitantur membra, palpitationem (παλμον) dixit, posteriorem (primam) vero, quae non fit nisi homo conetur partes quasdam movere tremorem vocavit.”

Under this authority the term palpitation may be employed to mark those morbid motions which chiefly characterise this disease, notwithstanding that this term has been anticipated by Sauvages, as characteristic he limbs of another species of tremor.^* The separation of palpitation of the limbs (Palmos of Galen, Tremor Coactus of de la Boë) from tremor, is the more necessary to be insisted on, since the distinction may assist in leading to a knowledge of the seat of the disease. It is also necessary to bear in mind, that this affection is distinguishable from tremor, by the agitation, in the former, occurring whilst the affected part is supported and unemployed, and being even checked by the adoption of voluntary motion; whilst in the latter, the tremor is induced immediately on bringing the parts into action. Thus an artist, afflicted with the malady here treated of, whilst his hand and arm is palpitating strongly, will seize his pencil, and the motions will be suspended, allowing 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.

This affection, which observation seems to authorise the being considered as a symptom peculiar to this disease, has been mentioned by few nosologists: it appears to have been first noticed by Gaubius, who says, “Cases occur in which the muscles duly excited into action by the impulse of the will, do then, with an unbidden agility, and with an impetus not to be repressed, accelerate their motion, and run before the unwilling mind. It is a frequent fault of the muscles belonging to speech, nor yet of these alone: I have seen one, who was able to run, but not to walk.”^†

Sauvages, referring to this symptom, says, another disease which has been very rarely seen by authors, appears to be referable to the same genus (Scelotyrbe, of which he makes Chorea sancti viti the first species); which, he says, “I think cannot be more fitly named than hastening or hurrying Scelotyrbe (Scelotyrbem festinantem, seu festiniam).”

Scelotyrbe festinans, he says, is a peculiar species of scelotyrbe, in which the patients, whilst wishing to walk in the ordinary mode, are forced to run, which has been seen by Carguet and by the illustrious Gaubius; a similar affection of the speech, when the tongue thus outruns the mind, is termed volubility. Mons. de Sauvages attributes this complaint to a want of flexibility in the muscular fibres. Hence, he supposes, that the patients make shorter steps, and strive with a more than common exertion or impetus to overcome the resistance; walking with a quick and hastened step, as if hurried along against their will. Chorea Viti, he says, attacks the youth of both sexes, but this disease only those advanced in years; and adds, that it has hitherto happened to him to have seen only two of these cases; and that he has nothing to offer respecting them, either in theory or practice.^‡

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

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 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 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 the 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 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 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 springy, 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.

Whilst conjecturing as to the cause of this disease, the following collected observations on the effects of injury to the medulla spinalis, by Sir Everard Home, become particularly deserving of attention. It thence appears, that none of the characteristic symptoms of this malady are produced by compression, laceration, or complete division of the medulla spinalis.

“Pressure upon the medulla spinalis of the neck, by coagulated blood, produced paralytic affections of the arms and legs; all the functions of the internal organs were carried on for thirty-five days, but the urine and stools passed involuntarily.^†

“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.^§

“When the medulla of the back was completely divided, there was momentary loss of sight, loss of memory of fifteen minutes, and permanent insensibility in all the lower parts of the body. The skin above the division of the spinal marrow perspired, that below did not. The wounded spinal marrow appeared to be extremely sensible.^* Philosophical Transactions, 1816, p. 485.

In two of the cases already noticed, symptoms of rheumatism had previously existed; and in Case IV the right arm, in which the palpitation began, was said to have been very violently affected with rheumatic pain to the fingers ends. The consideration of this case, in which the palpitation had been preceded, at a considerable distance of time, by this painful affection of the arm, led to the supposition that this latter circumstance might be the cause of the palpitations, and the other subsequent symptoms of this disease. This supposition naturally occasioned the attention to be eagerly fixed on the following case; and of course influenced the mode of treatment which was adopted.

A.B. subject to rheumatic affection of the deltoid muscle, had felt the usual inconveniences from it for two or three days; but at night found the pain had extended down the arm, along the inside of the fore-arm, and on the sides of the fingers, in which a continual tingling was felt. The pain, without being extremely intense, was such as effectually to prevent sleep: and seemed to follow the course of the brachial nerve. Whilst ascertaining the propriety of this conclusion, the pain was found to ramify, as it were, on the fore and back part of the chest; and was slightly augmented by drawing a deep breath.

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