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AN ESSAY ON THE SHAKING PALSY.
MEMBER OF THE ROYAL COLLEGE OF SURGEONS.
PRINTED BY WHITTINGHAM AND ROWLAND,
FOR SHERWOOD, NEELY, AND JONES,
The advantages which have been derived from the caution with which hypothetical statements are admitted, are in no instance more obvious than in those sciences which more particularly belong to the healing art. It therefore is necessary, that some conciliatory explanation should be offered for the present publication: in which, it is acknowledged, that mere conjecture takes the place of experiment; and, that analogy is the substitute for anatomical examination, the only sure foundation for pathological knowledge.
When, however, the nature of the subject, and the circumstances under which it has been here taken up, are considered, it is hoped that the offering of the following pages to the attention of the medical public, will not be severely censured. The disease, respecting which the present inquiry is made, is of a nature highly afflictive. Notwithstanding which, it has not yet obtained a place in the classification of nosologists; some have regarded its characteristic symptoms as distinct and different diseases, and others have given its name to diseases differing essentially from it; whilst the unhappy sufferer has considered it as an evil, from the domination of which he had no prospect of escape.
The disease is of long duration: to connect, therefore, the symptoms which occur in its later stages with those which mark its commencement, requires a continuance of observation of the same case, or at least a correct history of its symptoms, even for several years. Of both these advantages the writer has had the opportunities of availing himself; and has hence been led particularly to observe several other cases in which the disease existed in different stages of its progress. By these repeated observations, he hoped that he had been led to a probable conjecture as to the nature of the malady, and that analogy had suggested such means as might be productive of relief, and perhaps even of cure, if employed before the disease had been too long established. He therefore considered it to be a duty to submit his opinions to the examination of others, even in their present state of immaturity and imperfection.
To delay their publication did not, indeed, appear to be warrantable. The disease had escaped particular notice; and the task of ascertaining its nature and cause by anatomical investigation, did not seem likely to be taken up by those who, from their abilities and opportunities, were most likely to accomplish it. That these friends to humanity and medical science, who have already unveiled to us many of the morbid processes by which health and life is abridged, might be excited to extend their researches to this malady, was much desired; and it was hoped, that this might be procured by the publication of these remarks.
Should the necessary information be thus obtained, the writer will repine at no censure which the precipitate publication of mere conjectural suggestions may incur; but shall think himself fully rewarded by having excited the attention of those, who may point out the most appropriate means of relieving a tedious and most distressing malady.
CHAP. I. PAGE DEFINITION--HISTORY--ILLUSTRATIVE CASES 1
Involuntary tremulous motion, with lessened muscular power, in parts not in action and even when supported; with a propensity to bend the trunk forwards, and to pass from a walking to a running pace: the senses and intellects being uninjured.
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 pertinent; de qualibus hic agimus, quique tremores paralytoidei vocantur." Tremor has been adopted, as a genus, by almost every nosologist; but always unmarked, in their several definitions, by such characters as would embrace this disease. The celebrated Cullen, with his accustomed accuracy observes, "Tremorem, utpote semper symptomaticum, in numerum generum recipere nollem; species autem a Sauvagesio recensitas, prout mihi vel astheniæ vel paralysios, vel convulsionis symptomata esse 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.
[Footnote 1: Synopsis Nosologiæ Methodicæ.--Tom. ii. p. 195.]
So slight and nearly imperceptible are the first inroads of this malady, and so extremely slow is its progress, that it rarely happens, that the patient can form any recollection of the precise period of its commencement. The first symptoms perceived are, a slight sense of weakness, with a proneness to trembling in some particular part; sometimes in the head, but most commonly in one of the hands and arms. These symptoms gradually increase in the part first affected; and at an uncertain period, but seldom in less than twelvemonths or more, the morbid influence is felt in some other part. Thus assuming one of the 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 fæces from the rectum sometimes requiring mechanical aid. As the disease proceeds towards its last stage, the trunk is almost permanently bowed, the muscular power is more decidedly diminished, and the tremulous agitation becomes violent. The patient walks now with great difficulty, and unable any longer to support himself with his stick, he dares not venture on this exercise, unless assisted by an attendant, who walking backwards before him, prevents his falling forwards, by the pressure of his hands against the fore part of his shoulders. His words are now scarcely intelligible; and he is not only no longer able to feed himself, but when the food is conveyed to the mouth, so much are the actions of the muscles of the tongue, pharynx, &c. impeded by impaired action and perpetual agitation, that the food is with difficulty retained in the mouth until masticated; and then as difficultly swallowed. Now also, from the same cause, another very unpleasant circumstance occurs: the saliva fails of being directed to the back part of the fauces, and hence is continually draining from the mouth, mixed with the particles of food, which he is no longer able to clear from the inside of the mouth.
As the debility increases and the influence of the will over the muscles fades away, the tremulous agitation becomes more vehement. It now seldom leaves him for a moment; but even when exhausted nature seizes a small portion of sleep, the motion becomes so violent as not only to shake the bed-hangings, but even the floor and sashes of the room. The chin is now almost immoveably bent down upon the sternum. The slops with which he is attempted to be fed, with the saliva, are continually trickling from the mouth. The power of articulation is lost. The urine and fæces are passed involuntarily; and at the last, constant sleepiness, with slight delirium, and other marks of extreme exhaustion, announce the wished-for release.
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 fæces, and which precedes and follows their discharge in considerable quantity.
About a year since, on waking in the night, he found that he had nearly lost the use of the right side, and that the face was much drawn to the left side. His medical 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 a difficulty the having to step over a pin.
The preceding cases appear to belong to the same species: differing from each other, perhaps, only in the length of time which the disease had existed, and the stage at which it had arrived.
It has been seen in the preceding history of the disease, and in the accompanying cases, that certain affections, the tremulous agitations, and the almost invincible propensity to run, when wishing only to walk, each of which has been considered by nosologists as distinct diseases, appear to be pathognomonic symptoms of this malady. To determine in which of these points of view these affections ought to be regarded, an examination into their nature, and an inquiry into the opinions of preceding writers respecting them, seem necessary to be attempted.
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I. Involuntary tremulous motion, with lessened voluntary muscular power, in parts, not in action, and even supported.
It is necessary that the peculiar nature of this tremulous motion should be ascertained, as well for the sake of giving to it its proper 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 limb stops, or the part is supported, but returns when we will the limb to move; whence, he says, tremor is distinguished from every other kind of spasm.
[Footnote 2: Junckeri conspect. de tremore.]
[Footnote 3: Sect. V. Ubi autem solito pauciores deferunter ad eadem organa spiritus animales, imperfectæ ac imbecillæ observantur fieri eadem functiones, in motu tremulo et infirmo, nec diu durante, in visu debili, ac mox defatigato, &c.
Sect. XIX. Inæqualiter, inordinatè, ac præter contraque voluntatem moventur spiritus animales per nervos ad partes mobiles, in motu convulsivo, ac tremore, quassuve membrorum coacto.