Chapter 2

[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.

Distinguendus namque his tremor quiescente licet ac decumbente corpore molustus a motu tremulo, de quo dictum. Sect. V. Quique quiescente corpore cessat, eodemque iterum moto repetit.

Sect. XXV. Coactus tremor debetur animalibus spiritibus inordinatè ac continuo, cum aliquo impetu ad trementium membrorum musculos per nervos propulsis: sive fuerit is universalis, sive particularis, sive corpus fuerit ad huc robustum sive debile, Sylvii de la Boe. Prax. lib. i. cap. xlii.]

[Footnote 4: Nosolog. Methodic. Auctore Fr. Boissier de Sauvages, Tomi. II. Partis ii. p. 54. 1763.]

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[5]. "Binas has tremoris species[6] Galenus subtiliter distinxit, atque etiam diversis nominibus insignivit, tremor enim ([Greek: trom &]) 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 ([Greek: palmon]) dixit, posteriorem (_primam_) vero, quæ non fit nisi homo conetur partes quasdam movere tremorem vocavit."

[Footnote 5: Comment, in Herman. Boerhaav. Aphorismos. Tom. ii. p. 181.]

[Footnote 6: De tremore. Cap. 3 and 4. Chart, Tom. vii. p. 200-201.]

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 of another species of tremor[7]. 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.

[Footnote 7: Sect. XVI. _Tremor palpitans_, Preysinger classis morborum. _Palmos_ Galeni.

In tremoribus vulgaribus, æqualibus temporum intervallis, non musculus, sed artus ipsemet alternatim attollitur aut deprimitur, aut in oppositas partes it atque redit per minima tamen spatiola; in palpitatione verò sine ullo ordine musculi unius lacertus subito subsilit, nec regulariter continuoque movetur, sed nunc semel aut bis, nunc minimé intra idem tempus subsilit; an causa irritans in sensorio communi, an in musculo ipse palpitante Quærenda sit, ignoramus. _Nosologiæ Methodicæ_, Vol. I. p. 559. 1768.

But the adoption which Sauvages has made of this term, will not be regarded as an absolute prohibition from the employment of it here; since the _tremor palpitans_ of Sauvages should be considered rather as a palpitation of the muscles, whilst the motion which is so prominent a symptom in this disease, may be considered as a palpitation of the limbs.]

* * * * *

II. _A propensity to bend the trunk forwards, and to pass from a walking to a running pace._

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[8]."

[Footnote 8: Est et ubi musculi, recte quidem ad voluntatis nutum in actum concitati, injussa dein agilitate atque impetu non reprimendo motus suos accelerant, mentemque invitam præcurrunt. Vitium loquelæ musculis frequens, nec his solis tamen proprium: vidi enim, qui currere, non gradi, poterat[A].]

[Footnote A: Institution, Patholog. Medicinal. Auctore. H. D. Gaubio. 751.]

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[9].

[Footnote 9: Ad idem genus morbi altera species rarissima ab auctoribus prætervisa referenda videtur, quam non aptius nominari posse putem quàm scelotyrbem festinantem, seu festiniam.

SECT. II. _Scelotyrbe festinans_: est peculiaris scelotyrbes species in qua ægri solito more dum gradi volunt currere coguntur, quod videre est apud D. Carquet, et observavit Leydæ illustr. Gaubius. _Patholog. instit._ 751, et in loquela hæc _volubilitas_ dicitur quâ lingua præcurrit mentem. Video actu mulierem sexagenariam hoc affectam morbo siccitati nervorum tribuendo; laborat enim rheumatismo sicco, seu ab acrimonia sanguinis, dolores nocte a calore recrudescunt, à thermis non sublevantur: ei præscripsi phlebotomiam, et præmissis jusculis ex lactucâ, endiviâ, et collo arietis, lene catharticum, inde vero lacticinia.

Est affinitas cum scelotyrbe, chorea viti, deest flexibilitas in fibris musculorum; unde motus breves edunt, et conatu seu impetu solito majori, cum resistentiam illam superare nituntur, velut inviti festinant, ac præcipiti seu concitato passu gradiuntur. Chorea viti pueros, puellasve impuberes aggreditur; festinia vero senes, et duos tantum hactenus observare mihi contigit. Quam multos autem videmus morbos, paucissimosque observamus. De theoria et pràxi nihil habeo quod dicam; etenim sola experienta praxin cujusvis morbi determinat, et ex hac pro felici vel infausto successu theoria dein elicienda est. _Nosolog. Methodic._ Auctore, Fr. Boissier de Sauvages. Tomi. II. Part ii. p. 108.]

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.

CHAP. III.

SHAKING PALSY DISTINGUISHED FROM OTHER DISEASES WITH WHICH IT MAY BE CONFOUNDED.

Treating 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 endeavouring to mark its diagnostic characters. It is sufficient, in general, to point out the characteristic differences which are observable between 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 nosologists; 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 palsied limbs become affected with tremulous motions, be confounded with this disease. In those cases the abolition or diminution of voluntary muscular 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 affections 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 been here denominated Shaking Palsy. Dr. Kirkland, in his commentary on Apoplectic and Paralytic Affections, &c. 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, and 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 were 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, "A poor boy, about twelve or thirteen years of age, was seized with a Shaking Palsy. His legs became useless, and together with his head and hands, were in continual agitation; after many weeks trial of various remedies, my assistance was desired.

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

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

The term Shaking Palsy is evidently inapplicable to the first of these cases, which appears to have belonged more properly to the genus _Convulsio_, of Cullen, or to _Hieranosos_ of Linnæus and Vogel[10].

[Footnote 10: Corporis agitatio continua, indolens, convulsiva, cum sensibilitate.--_Linn._

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

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

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

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

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

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

CHAP. IV.

PROXIMATE CAUSE--REMOTE CAUSES--ILLUSTRATIVE CASES.

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

SUPPOSED PROXIMATE CAUSE.

A diseased state of the _medulla spinalis_, in that part which is contained in the canal, formed by the superior cervical vertebræ, and extending, as the disease proceeds, to the _medulla oblongata_.

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

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

The great degree of mobility in that portion of the spine which is formed by the superior cervical vertebræ, 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 vertebræ, derangement of structure in the medulla, or in its membranes, thickening or even ulceration of the theca, effusion of fluids, &c.

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

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

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

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

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